=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306483193
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLEMAGNE PREVILON DRIVER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2019
-----------------------------------------------------
Last Update Date | 11/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4323 CARMELO OAKS CT
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95841-3474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-532-0058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4323 CARMELO OAKS CT
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95841-3474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-532-0058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171WV0202X
-----------------------------------------------------
Taxonomy Name | Vehicle Modifications Contractor
-----------------------------------------------------
License Number | GNB32019-03411
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------