Provider Demographics
NPI:1568220788
Name:CARACHURE CHARCO, TEODORO LAURO (NP)
Entity Type:Individual
Prefix:
First Name:TEODORO
Middle Name:LAURO
Last Name:CARACHURE CHARCO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 MITCHELL AVE APT 91
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6363
Mailing Address - Country:US
Mailing Address - Phone:714-409-7718
Mailing Address - Fax:
Practice Address - Street 1:3030 W OLYMPIC BLVD STE 217
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6507
Practice Address - Country:US
Practice Address - Phone:213-550-2159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029381363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health