Provider Demographics
NPI:1629183496
Name:CHARLES ETUK
Entity type:Organization
Organization Name:CHARLES ETUK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:ETUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-241-0886
Mailing Address - Street 1:1011 S GAFFEY ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-4033
Mailing Address - Country:US
Mailing Address - Phone:310-241-0886
Mailing Address - Fax:310-241-0876
Practice Address - Street 1:1011 S GAFFEY ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-4033
Practice Address - Country:US
Practice Address - Phone:310-241-0886
Practice Address - Fax:310-241-0876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45847332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5783230001Medicare NSC