MEDICARE: CHARLES EDMUND FTACEK MS, CNS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133NN1002X	Nutrition Education Nutritionist

General Provider Information

NPI Number	:	1386365682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES EDMUND FTACEK MS, CNS

Provider Business Mailing Address
First Line	:	4078 HAMILTON ST APT 3
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-6144
Country	:	US
Telephone Number	:	615-815-6183
Fax Number	:

Provider Business Practice Location Address
First Line	:	4078 HAMILTON ST APT 3
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-6144
Country	:	US
Telephone Number	:	615-815-6183
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2022
Last Update Date	:	10/18/2022

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