Healthcare Provider Details

I. General information

NPI: 1619022720
Provider Name (Legal Business Name): CHARLES PHILLIP GAGARIN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13766 CENTER ST SUITE 211
CARMEL VALLEY CA
93924-9693
US

IV. Provider business mailing address

13766 CENTER ST SUITE 211
CARMEL VALLEY CA
93924-9693
US

V. Phone/Fax

Practice location:
  • Phone: 831-659-8009
  • Fax: 831-659-8009
Mailing address:
  • Phone: 831-659-8009
  • Fax: 831-659-8009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC 13520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: