Healthcare Provider Details

I. General information

NPI: 1194094243
Provider Name (Legal Business Name): CHALITA PHOTIKOE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 LOMITA DR B
MILL VALLEY CA
94941-1451
US

IV. Provider business mailing address

147 LOMITA DR B
MILL VALLEY CA
94941-1451
US

V. Phone/Fax

Practice location:
  • Phone: 415-225-5285
  • Fax:
Mailing address:
  • Phone: 415-225-5285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number10104
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: