=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174688527
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES BROWN HEALTHCARE, A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 W 14TH ST SUITE 16
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-7800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-519-8767
-----------------------------------------------------
Fax | 888-288-0382
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 W 14TH ST SUITE 16
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-7800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-519-8767
-----------------------------------------------------
Fax | 888-288-0382
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. CHARLES VICTOR BROWN JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-519-8767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | A49923
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------