Provider Demographics
NPI:1104919661
Name:HOUGH, CHARLES L JR (DC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:HOUGH
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11770 WARNER AVE
Mailing Address - Street 2:SUITE 122
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-2663
Mailing Address - Country:US
Mailing Address - Phone:714-633-9532
Mailing Address - Fax:
Practice Address - Street 1:11770 WARNER AVE
Practice Address - Street 2:SUITE 122
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-2663
Practice Address - Country:US
Practice Address - Phone:714-633-9532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17196111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABC666ZOtherPTAN
DC17196OtherCHIROPRACTIC LICENSE
CADC0171960OtherBLUE SHIELD