Basic Information
| Provider Information | |||||||||
| NPI: | 1760998181 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ESSARY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2487 CAMINITO VENIDO | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921071504 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3978 SORRENTO VALLEY BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584280222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2017 | ||||||||
| LastUpdateDate: | 12/20/2017 | ||||||||
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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 | 106S00000X | RBT-17-29751 | CA | Y | 193400000X SINGLE SPECIALTY GROUP |
No ID Information.