Healthcare Provider Details

I. General information

NPI: 1841646809
Provider Name (Legal Business Name): CHARLES FAGENHOLZ DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 AIRWAY AVE U-3
COSTA MESA CA
92626-4607
US

IV. Provider business mailing address

21264 BEACH BLVD #203
HUNTINGTON BEACH CA
92648-5482
US

V. Phone/Fax

Practice location:
  • Phone: 714-754-8008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number33312
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: