=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679834113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES A GARRETSON MD SOLE MBR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2012
-----------------------------------------------------
Last Update Date | 06/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2721 OLIVE HWY STE 2
-----------------------------------------------------
City | OROVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95966-6115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-533-6100
-----------------------------------------------------
Fax | 530-533-6102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2721 OLIVE HWY STE 2
-----------------------------------------------------
City | OROVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95966-6115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-533-6100
-----------------------------------------------------
Fax | 530-533-6102
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHARLES A GARRETSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 530-533-6100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | G86610
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------