Charles Luke Enomoto Sr.

Key facts

NPI

1760125843

Entity type

Individual (NPI type 1)

Primary specialty

Addiction (Substance Use Disorder) Counselor 101YA0400X

License

A057340620 (CA)

Practice address

20 Lake Blvd
Redding, CA 96003-2512

Phone

(530) 229-1416

NPI assigned

Apr 18, 2022

Sex

Male

Sole proprietor

Yes

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

State licenses

Specialties & licenses

Addresses

Other identifiers

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Apr 18, 2022.

{
    "created_epoch": "1650240000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1650240000000",
    "number": "1760125843",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12591 SHALON DR",
            "city": "REDDING",
            "state": "CA",
            "postal_code": "960030382",
            "telephone_number": "530-510-3149"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20 LAKE BLVD",
            "city": "REDDING",
            "state": "CA",
            "postal_code": "960032512",
            "telephone_number": "530-229-1416"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ENOMOTO",
        "first_name": "CHARLES",
        "middle_name": "LUKE",
        "name_suffix": "Sr.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2022-04-18",
        "last_updated": "2022-04-18",
        "certification_date": "2022-04-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP1600X",
            "taxonomy_group": "",
            "desc": "Counselor, Pastoral",
            "state": "CA",
            "license": null,
            "primary": false
        },
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "CA",
            "license": "A057340620",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TRI-WEST",
            "identifier": "1912215492",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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All providers in Redding, CA · Addiction (Substance Use Disorder) Counselor in California