Provider Demographics
NPI:1386841039
Name:BREJCHA, CHARLES THOMAS (MA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:THOMAS
Last Name:BREJCHA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE # 55745
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:323-906-1275
Mailing Address - Fax:323-906-1414
Practice Address - Street 1:2654 GRIFFITH PARK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-2520
Practice Address - Country:US
Practice Address - Phone:323-906-1275
Practice Address - Fax:323-906-1414
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPE TEM 4179231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWAU2530AMedicare PIN