Basic Information
| Provider Information | |||||||||
| NPI: | 1780967455 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLES R STEVENS, A PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1665 S IMPERIAL AVE STE D | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604820212 | ||||||||
| FaxNumber: | 7604820166 | ||||||||
| Practice Location | |||||||||
| Address1: | 1665 S IMPERIAL AVE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604820212 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2011 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | STEVENS | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7604820212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHARLES R STEVENS, A PROFESSIONAL CORPORATION | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.