Healthcare Provider Details

I. General information

NPI: 1982209854
Provider Name (Legal Business Name): CHARLES HOLBROOK SWAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 GREENTREE RD
ENCINITAS CA
92024-3022
US

IV. Provider business mailing address

1712 GREENTREE RD
ENCINITAS CA
92024-3022
US

V. Phone/Fax

Practice location:
  • Phone: 760-613-8719
  • Fax:
Mailing address:
  • Phone: 760-613-8719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4922
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: