Provider Demographics
NPI:1730267071
Name:FUQUA, CHARLES SCOTT (REGISTERED PHYSICAL)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:SCOTT
Last Name:FUQUA
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Gender:M
Credentials:REGISTERED PHYSICAL
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Mailing Address - Street 1:6560 GREENBACK LANE
Mailing Address - Street 2:# 100
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621
Mailing Address - Country:US
Mailing Address - Phone:916-723-3372
Mailing Address - Fax:916-722-5098
Practice Address - Street 1:6560 GREENBACK LANE
Practice Address - Street 2:# 100
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621
Practice Address - Country:US
Practice Address - Phone:916-723-3372
Practice Address - Fax:916-722-5098
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2008-02-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA9856225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT98560Medicare PIN