Healthcare Provider Details

I. General information

NPI: 1477276533
Provider Name (Legal Business Name): CHARLES SANDERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12141 BROOKHURST ST STE 201
GARDEN GROVE CA
92840-2865
US

IV. Provider business mailing address

12141 BROOKHURST ST STE 201
GARDEN GROVE CA
92840-2865
US

V. Phone/Fax

Practice location:
  • Phone: 657-261-7140
  • Fax: 714-922-1032
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA063280923
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: