Healthcare Provider Details

I. General information

NPI: 1477149284
Provider Name (Legal Business Name): CHARLES NICHOLAUS TABONE NATUROPATHIC DOCTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11640 SAN VICENTE BLVD STE 103
LOS ANGELES CA
90049-6535
US

IV. Provider business mailing address

11640 SAN VICENTE BLVD STE 103
LOS ANGELES CA
90049-6535
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-7925
  • Fax:
Mailing address:
  • Phone: 310-820-7925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberND1209
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: