Provider Demographics
NPI:1306483193
Name:PREVILON, CHARLEMAGNE (DRIVER)
Entity type:Individual
Prefix:
First Name:CHARLEMAGNE
Middle Name:
Last Name:PREVILON
Suffix:
Gender:M
Credentials:DRIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 CARMELO OAKS CT
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-3474
Mailing Address - Country:US
Mailing Address - Phone:916-532-0058
Mailing Address - Fax:
Practice Address - Street 1:4323 CARMELO OAKS CT
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-3474
Practice Address - Country:US
Practice Address - Phone:916-532-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-29
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGNB32019-03411171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WV0202XOther Service ProvidersContractorVehicle ModificationsGroup - Single Specialty