=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609947860
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES GYDEN RPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2006
-----------------------------------------------------
Last Update Date | 10/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 426 W MANCHESTER BLVD
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90301-1110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-419-7600
-----------------------------------------------------
Fax | 310-419-7667
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3016 W 78TH PL
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90305-1030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-752-0380
-----------------------------------------------------
Fax | 310-419-7667
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251H1200X
-----------------------------------------------------
Taxonomy Name | Hand Physical Therapist
-----------------------------------------------------
License Number | 007240
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number | 007240
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 007240
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 007240
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------