Provider Demographics
NPI:1174688527
Name:CHARLES BROWN HEALTHCARE, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:CHARLES BROWN HEALTHCARE, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:310-519-8767
Mailing Address - Street 1:501 W 14TH ST
Mailing Address - Street 2:SUITE 16
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-7800
Mailing Address - Country:US
Mailing Address - Phone:310-519-8767
Mailing Address - Fax:888-288-0382
Practice Address - Street 1:501 W 14TH ST
Practice Address - Street 2:SUITE 16
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-7800
Practice Address - Country:US
Practice Address - Phone:310-519-8767
Practice Address - Fax:888-288-0382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49923261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI26044Medicare UPIN