Healthcare Provider Details

I. General information

NPI: 1265432710
Provider Name (Legal Business Name): LEO CHARLES CRAYCHEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28714 VALLEY CENTER RD #F
VALLEY CENTER CA
92082-6554
US

IV. Provider business mailing address

28714 VALLEY CENTER RD #L
VALLEY CENTER CA
92082-6554
US

V. Phone/Fax

Practice location:
  • Phone: 760-749-7770
  • Fax: 760-751-9988
Mailing address:
  • Phone: 760-749-7770
  • Fax: 760-751-9988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG59127
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: