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General NPI Number Information
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NPI Number | 1396995718
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Entity Type | Organization
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Legal Business Name | ALTERED STATES RESEARCH GROUP, INC.
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Dates
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Enumeration Date | 09/22/2008
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Last Update Date | 09/22/2008
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Provider Practice Location Address
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Address Line | 3511 CAMINO DEL RIO S SUITE 404
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City | SAN DIEGO
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State | CA
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Zip | 92108-4003
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Country | US
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Telephone | 619-481-8416
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Fax | 619-516-3993
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Provider Business Mailing Address
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Address Line | 3511 CAMINO DEL RIO S SUITE 404
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City | SAN DIEGO
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State | CA
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Zip | 92108-4003
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Country | US
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Telephone | 619-481-8416
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Fax | 619-516-3993
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. CHARLES I. KNOLL
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Credential | M.D.
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Telephone | 619-481-8416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | A100046
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License Number State | CA
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