Provider Demographics
NPI:1841646809
Name:FAGENHOLZ, CHARLES (DC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:FAGENHOLZ
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 1:21264 BEACH BLVD
Mailing Address - Street 2:#203
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-5482
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3151 AIRWAY AVE
Practice Address - Street 2:U-3
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4607
Practice Address - Country:US
Practice Address - Phone:714-754-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33312111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner