Provider Demographics
NPI:1487291480
Name:BULDA, CHARLES SABLAN
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:SABLAN
Last Name:BULDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21501 S VERMONT AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-1976
Mailing Address - Country:US
Mailing Address - Phone:310-938-4292
Mailing Address - Fax:
Practice Address - Street 1:15115 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4101
Practice Address - Country:US
Practice Address - Phone:310-532-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49969225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant