Provider Demographics
NPI:1508828799
Name:TRUONG, CHARLIE THANG (RPT, ATC)
Entity Type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:THANG
Last Name:TRUONG
Suffix:
Gender:M
Credentials:RPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10808 CHURCHILL PL
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1347
Mailing Address - Country:US
Mailing Address - Phone:714-891-5453
Mailing Address - Fax:714-891-5346
Practice Address - Street 1:14571 MAGNOLIA ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5574
Practice Address - Country:US
Practice Address - Phone:714-891-5453
Practice Address - Fax:714-891-5346
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25387225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT25387Medicare ID - Type UnspecifiedPHYSICAL THERAPIST