Provider Demographics
NPI:1619348109
Name:DUBOURDIEU, CHARLES III (CPO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:DUBOURDIEU
Suffix:III
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 IMPERIAL HWY
Mailing Address - Street 2:900 ANNEX A
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-3456
Mailing Address - Country:US
Mailing Address - Phone:562-401-8115
Mailing Address - Fax:562-803-5569
Practice Address - Street 1:7601 IMPERIAL HWY
Practice Address - Street 2:900 ANNEX A
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-3456
Practice Address - Country:US
Practice Address - Phone:562-401-8115
Practice Address - Fax:562-803-5569
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO 1803335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier