Provider Demographics
NPI:1821292459
Name:MARISA, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MARISA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W BLAINE STREET
Mailing Address - Street 2:SUITE C/D
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507
Mailing Address - Country:US
Mailing Address - Phone:951-955-2233
Mailing Address - Fax:951-955-2233
Practice Address - Street 1:1126 N GRAND AVE
Practice Address - Street 2:SUITE D
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1551
Practice Address - Country:US
Practice Address - Phone:626-967-1667
Practice Address - Fax:626-967-6027
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner