Healthcare Provider Details

I. General information

NPI: 1447999388
Provider Name (Legal Business Name): CHARLESON PRINCE GODIO AGUSTIN DPT, CMT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 GARDEN GROVE BLVD
WESTMINSTER CA
92683-1976
US

IV. Provider business mailing address

6000 GARDEN GROVE BLVD APT 238
WESTMINSTER CA
92683-1955
US

V. Phone/Fax

Practice location:
  • Phone: 562-270-1605
  • Fax:
Mailing address:
  • Phone: 626-756-5036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number79389
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: