Healthcare Provider Details

I. General information

NPI: 1174258842
Provider Name (Legal Business Name): CHARLES NEBO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4240 W 62ND ST
LOS ANGELES CA
90043-3615
US

IV. Provider business mailing address

5757 W CENTURY BLVD STE 303
LOS ANGELES CA
90045-6409
US

V. Phone/Fax

Practice location:
  • Phone: 323-290-2540
  • Fax:
Mailing address:
  • Phone: 818-439-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: