Provider Demographics
NPI:1447999388
Name:AGUSTIN, CHARLESON PRINCE GODIO (DPT, CMT, CSCS)
Entity type:Individual
Prefix:DR
First Name:CHARLESON PRINCE
Middle Name:GODIO
Last Name:AGUSTIN
Suffix:
Gender:M
Credentials:DPT, CMT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 GARDEN GROVE BLVD APT 238
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-1955
Mailing Address - Country:US
Mailing Address - Phone:626-756-5036
Mailing Address - Fax:
Practice Address - Street 1:6000 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-1976
Practice Address - Country:US
Practice Address - Phone:562-270-1605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79389225700000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist