Provider Demographics
NPI:1386858959
Name:SPINA, CHARLES T (PT,JSCC,CEAS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
Last Name:SPINA
Suffix:
Gender:M
Credentials:PT,JSCC,CEAS
Other - Prefix:
Other - First Name:CHUCK
Other - Middle Name:
Other - Last Name:SPINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT,JSCC,CEAS
Mailing Address - Street 1:6596 N RAISINA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-3945
Mailing Address - Country:US
Mailing Address - Phone:916-214-3941
Mailing Address - Fax:
Practice Address - Street 1:7005 N MAPLE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-8009
Practice Address - Country:US
Practice Address - Phone:559-325-3503
Practice Address - Fax:559-325-3504
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT15431225100000X
2251E1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACK761UOtherMEDICARE PTAN
CACK761UOtherMEDICARE PTAN
CAZZZ32774ZMedicare UPIN