Provider Demographics
NPI:1912489162
Name:DOUGLAS, CHARISSA (DC)
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:CHARISSA
Other - Middle Name:
Other - Last Name:TAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:17330 BEAR VALLEY RD
Mailing Address - Street 2:STE 105
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395
Mailing Address - Country:US
Mailing Address - Phone:760-245-8182
Mailing Address - Fax:760-245-2123
Practice Address - Street 1:17330 BEAR VALLEY RD
Practice Address - Street 2:STE 105
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395
Practice Address - Country:US
Practice Address - Phone:760-245-8182
Practice Address - Fax:760-245-2123
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC36310111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor