Healthcare Provider Details

I. General information

NPI: 1386365682
Provider Name (Legal Business Name): CHARLES EDMUND FTACEK DCN, MS, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 S MAIN ST # 544
SEBASTOPOL CA
95472-4208
US

IV. Provider business mailing address

321 S MAIN ST # 544
SEBASTOPOL CA
95472-4208
US

V. Phone/Fax

Practice location:
  • Phone: 615-815-6183
  • Fax:
Mailing address:
  • Phone: 615-815-6183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: