=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568754869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES PARK BURCHETTE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2011
-----------------------------------------------------
Last Update Date | 12/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5820 YOLANDA AVE APT 8
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-1450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-404-8336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5820 YOLANDA AVE APT 8
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-1450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-404-8336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WS0200X
-----------------------------------------------------
Taxonomy Name | School Registered Nurse
-----------------------------------------------------
License Number | 716149
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------