Provider Demographics
NPI:1023399680
Name:CHARLTON, LANI (CMT, LMT)
Entity type:Individual
Prefix:MS
First Name:LANI
Middle Name:
Last Name:CHARLTON
Suffix:
Gender:F
Credentials:CMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:CA
Mailing Address - Zip Code:95623-0108
Mailing Address - Country:US
Mailing Address - Phone:530-621-4110
Mailing Address - Fax:530-621-4116
Practice Address - Street 1:5856 MOTHER LODE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-8203
Practice Address - Country:US
Practice Address - Phone:530-621-4110
Practice Address - Fax:530-621-4116
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17703225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist