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General NPI Number Information
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NPI Number | 1689829418
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Entity Type | Individual
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Provider Name | CHARLOTTE B VDOVYCHENKO
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Gender | Female
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Dates
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Enumeration Date | 11/20/2008
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Last Update Date | 02/04/2016
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Provider Practice Location Address
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Address Line | 2801 BRAZOS BLVD APT 4309
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City | EULESS
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State | TX
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Zip | 76039-5435
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Country | US
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Telephone | 817-915-1800
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Fax | 682-503-6649
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Provider Business Mailing Address
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Address Line | PO BOX 59
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City | EULESS
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State | TX
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Zip | 76039-0059
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Country | US
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Telephone | 817-915-1800
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Fax | 682-503-6649
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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 | 246RM2200X
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Taxonomy Name | Medical Laboratory Technician
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License Number | 4075
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License Number State | WI
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