Healthcare Provider Details

I. General information

NPI: 1710369988
Provider Name (Legal Business Name): CHARLES WARTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 UNIVERSITY AVE
BERKELEY CA
94703-1515
US

IV. Provider business mailing address

4650 W SUNSET BLVD # 53
LOS ANGELES CA
90027-6062
US

V. Phone/Fax

Practice location:
  • Phone: 510-548-9716
  • Fax:
Mailing address:
  • Phone: 323-361-3849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: