MEDICARE: DR. LAC K LE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	0101034585	VA

General Provider Information

NPI Number	:	1760460265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAC K LE M.D.

Provider Business Mailing Address
First Line	:	5816 SPINNAKER COVE RD
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-2127
Country	:	US
Telephone Number	:	804-524-7429
Fax Number	:	804-524-7069

Provider Business Practice Location Address
First Line	:	26317 W. WASHINGTON ST
Second Line	:	CENTRAL STATE HOSPITAL
City	:	PETERSBURG
State	:	VA
Zip	:	23803
Country	:	US
Telephone Number	:	804-524-7429
Fax Number	:	804-524-7069

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	07/08/2007

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