MEDICARE: MR. CHARLIE THANG TRUONG RPT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT25387	CA

General Provider Information

NPI Number	:	1508828799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLIE THANG TRUONG RPT, ATC

Provider Business Mailing Address
First Line	:	10808 CHURCHILL PL
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92782-1347
Country	:	US
Telephone Number	:	714-891-5453
Fax Number	:	714-891-5346

Provider Business Practice Location Address
First Line	:	14571 MAGNOLIA ST
Second Line	:	SUITE 201
City	:	WESTMINSTER
State	:	CA
Zip	:	92683-5574
Country	:	US
Telephone Number	:	714-891-5453
Fax Number	:	714-891-5346

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2006
Last Update Date	:	07/08/2007

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