Provider Demographics
NPI:1154624443
Name:CHARTER HEALTH CARE GROUP LLC
Entity type:Organization
Organization Name:CHARTER HEALTH CARE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-644-4965
Mailing Address - Street 1:970 S VILLAGE OAKS DR STE 102
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-0609
Mailing Address - Country:US
Mailing Address - Phone:626-915-7490
Mailing Address - Fax:626-951-7490
Practice Address - Street 1:970 S VILLAGE OAKS DR
Practice Address - Street 2:SUITE 102
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3626
Practice Address - Country:US
Practice Address - Phone:626-915-7490
Practice Address - Fax:626-915-6050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAHHA08076F251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA08076FMedicaid
CA058076Medicare UPIN