Healthcare Provider Details

I. General information

NPI: 1639341944
Provider Name (Legal Business Name): TRACY D. CHARLES M.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27574 COMMERCE CENTER DR SUITE 236
TEMECULA CA
92590-2535
US

IV. Provider business mailing address

27574 COMMERCE CENTER DR SUITE 232
TEMECULA CA
92590-2500
US

V. Phone/Fax

Practice location:
  • Phone: 951-695-9648
  • Fax:
Mailing address:
  • Phone: 951-695-9648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA46552
License Number StateCA

VIII. Authorized Official

Name: TRACY DENISE CHARLES
Title or Position: OWNER
Credential: M.D.
Phone: 951-695-9648