Basic Information
| Provider Information | |||||||||
| NPI: | 1710167168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANIELS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | SHANE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34145 PACIFIC COAST HWY | ||||||||
| Address2: | #603 | ||||||||
| City: | DANA POINT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926292808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619499966 | ||||||||
| FaxNumber: | 9493629503 | ||||||||
| Practice Location | |||||||||
| Address1: | 34145 PACIFIC COAST HWY | ||||||||
| Address2: | #603 | ||||||||
| City: | DANA POINT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926292808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6619499966 | ||||||||
| FaxNumber: | 9493629503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2007 | ||||||||
| LastUpdateDate: | 11/10/2011 | ||||||||
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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 | 208100000X | A94985 | CA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.