Healthcare Provider Details

I. General information

NPI: 1306763040
Provider Name (Legal Business Name): CHARLES DE CUIR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14500 ROSCOE BLVD
PANORAMA CITY CA
91402-4190
US

IV. Provider business mailing address

4007 W 60TH ST
LOS ANGELES CA
90043-3636
US

V. Phone/Fax

Practice location:
  • Phone: 818-714-2022
  • Fax:
Mailing address:
  • Phone: 213-804-5503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberS0717589
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberS0717589
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: