Basic Information
| Provider Information | |||||||||
| NPI: | 1063006765 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LORENA | ||||||||
| FirstName: | CHARLES LAUREN | ||||||||
| MiddleName: | MACASINAG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6918 FLORIDO RD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891784026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8484596297 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3312 W CHARLESTON BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891021829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029712300 | ||||||||
| FaxNumber: | 7029034447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2021 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.