Provider Demographics
NPI:1548250806
Name:TLACHAC, CHARLOTTE ADELE (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:ADELE
Last Name:TLACHAC
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-3102
Mailing Address - Country:US
Mailing Address - Phone:510-522-5097
Mailing Address - Fax:510-522-0815
Practice Address - Street 1:1429 HIGH ST
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-3102
Practice Address - Country:US
Practice Address - Phone:510-522-5097
Practice Address - Fax:510-522-0815
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA065737152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD000010Medicaid
CAT10359Medicare UPIN
CAGSD000010Medicaid
CA0262360001Medicare NSC