Healthcare Provider Details

I. General information

NPI: 1447529268
Provider Name (Legal Business Name): CHARLISA EVONNE HAYNES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43520 DIVISION ST
LANCASTER CA
93535-4089
US

IV. Provider business mailing address

108 W VICTORIA ST
GARDENA CA
90248-3523
US

V. Phone/Fax

Practice location:
  • Phone: 661-266-4783
  • Fax:
Mailing address:
  • Phone: 661-726-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: