Healthcare Provider Details

I. General information

NPI: 1215331475
Provider Name (Legal Business Name): CHARLES EDWARD RICHARDSON III D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7709 FOOTHILL BLVD
TUJUNGA CA
91042-2120
US

IV. Provider business mailing address

6738 HINDS AVE
NORTH HOLLYWOOD CA
91606-1611
US

V. Phone/Fax

Practice location:
  • Phone: 818-804-0525
  • Fax: 818-352-8116
Mailing address:
  • Phone: 818-967-9874
  • Fax: 818-352-8116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC33073
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: