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General NPI Number Information
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NPI Number | 1144226291
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Entity Type | Individual
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Provider Name | CHARLES WARREN LACKEY MD
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Gender | Male
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Dates
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Enumeration Date | 06/23/2005
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Last Update Date | 03/02/2023
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Provider Practice Location Address
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Address Line | 822 W 4TH ST
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City | LEADVILLE
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State | CO
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Zip | 80461-3861
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Country | US
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Telephone | 719-486-1264
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Fax |
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Provider Business Mailing Address
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Address Line | 822 W 4TH ST
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City | LEADVILLE
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State | CO
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Zip | 80461-3861
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Country | US
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Telephone | 719-486-1264
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 19438
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License Number State | CO
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