Provider Demographics
NPI:1366847212
Name:DAVID, CHARLES JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:DAVID
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16701 LYNN LN APT B
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3463
Mailing Address - Country:US
Mailing Address - Phone:678-231-6011
Mailing Address - Fax:
Practice Address - Street 1:5810 DOWNEY AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-4517
Practice Address - Country:US
Practice Address - Phone:562-380-2178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10582225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant