Healthcare Provider Details

I. General information

NPI: 1942170162
Provider Name (Legal Business Name): CHARON SIMMONS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 BAKER ST STE A
COSTA MESA CA
92626-4566
US

IV. Provider business mailing address

275 BAKER ST STE A
COSTA MESA CA
92626-4566
US

V. Phone/Fax

Practice location:
  • Phone: 714-361-6760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: