Healthcare Provider Details

I. General information

NPI: 1104540368
Provider Name (Legal Business Name): CHARLOT T LE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2022
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DANIEL BURNHAM CT
SAN FRANCISCO CA
94109-5455
US

IV. Provider business mailing address

1 DANIEL BURNHAM CT
SAN FRANCISCO CA
94109-5455
US

V. Phone/Fax

Practice location:
  • Phone: 415-409-7364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number2022043467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: