Basic Information
| Provider Information | |||||||||
| NPI: | 1053449470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALTENBERN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CCP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10930 N TATUM BLVD | ||||||||
| Address2: | #103 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850286069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022637600 | ||||||||
| FaxNumber: | 6022120365 | ||||||||
| Practice Location | |||||||||
| Address1: | 10930 N TATUM BLVD | ||||||||
| Address2: | #103 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850286069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022637600 | ||||||||
| FaxNumber: | 6022120365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
No ID Information.