Healthcare Provider Details

I. General information

NPI: 1720942022
Provider Name (Legal Business Name): CHARLIE DAVIS RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1279 ALICANTE DR
PACIFICA CA
94044-4306
US

IV. Provider business mailing address

1279 ALICANTE DR
PACIFICA CA
94044-4306
US

V. Phone/Fax

Practice location:
  • Phone: 612-999-3662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86147795
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: