Provider Demographics
NPI:1528604980
Name:SMALL, CHARLES PATRICK (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PATRICK
Last Name:SMALL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 REDONDO AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-1969
Mailing Address - Country:US
Mailing Address - Phone:562-668-4123
Mailing Address - Fax:
Practice Address - Street 1:1213 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5103
Practice Address - Country:US
Practice Address - Phone:310-545-4188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34599111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor