Individual
CHARLISA EVONNE HAYNES
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
43520 DIVISION ST, LANCASTER, CA 93535-4089
(661) 266-4783
Mailing address
108 W VICTORIA ST, GARDENA, CA 90248-3523
(661) 726-5500
Taxonomy
Speciality
Code
Description
License number
State
225400000X
Rehabilitation Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
#95-2633765
MEDI-CAL
CA
Enumeration date
12/22/2011
Last updated
08/19/2016
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