Provider Demographics
NPI:1699530436
Name:DR CHARLES SMALL SPORT AND SPINE CHIROPRACTIC AND PHYSICAL MEDICINE
Entity type:Organization
Organization Name:DR CHARLES SMALL SPORT AND SPINE CHIROPRACTIC AND PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:P
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-545-4188
Mailing Address - Street 1:1213 N SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5103
Mailing Address - Country:US
Mailing Address - Phone:310-545-4188
Mailing Address - Fax:
Practice Address - Street 1:1213 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5103
Practice Address - Country:US
Practice Address - Phone:310-545-4188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty