Healthcare Provider Details

I. General information

NPI: 1538777115
Provider Name (Legal Business Name): CHARLES HORICE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 E 84TH ST
LOS ANGELES CA
90003-3104
US

IV. Provider business mailing address

414 E 84TH ST
LOS ANGELES CA
90003-3104
US

V. Phone/Fax

Practice location:
  • Phone: 323-816-6399
  • Fax:
Mailing address:
  • Phone: 323-816-6399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: