Healthcare Provider Details

I. General information

NPI: 1366421083
Provider Name (Legal Business Name): CHARLES A STULGA D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 BERGQUIST DR STE. 1, ATTN: CREDENTIALS (CMC)
LACKLAND A F B TX
78236-5300
US

IV. Provider business mailing address

2200 BERGQUIST DR ATTN: CREDENTIALS (CMC)
LACKLAND A F B TX
78236-9908
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-3715
  • Fax: 210-292-2854
Mailing address:
  • Phone: 210-292-3715
  • Fax: 210-292-2854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5121
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: