Provider Demographics
NPI:1386365682
Name:FTACEK, CHARLES EDMUND (MS, CNS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDMUND
Last Name:FTACEK
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Gender:M
Credentials:MS, CNS
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4078 HAMILTON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-6144
Mailing Address - Country:US
Mailing Address - Phone:615-815-6183
Mailing Address - Fax:
Practice Address - Street 1:4078 HAMILTON ST APT 3
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-6144
Practice Address - Country:US
Practice Address - Phone:615-815-6183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education