Provider Demographics
NPI:1194094243
Name:PHOTIKOE, CHALITA (LAC)
Entity type:Individual
Prefix:MS
First Name:CHALITA
Middle Name:
Last Name:PHOTIKOE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 LOMITA DR
Mailing Address - Street 2:B
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-1451
Mailing Address - Country:US
Mailing Address - Phone:415-225-5285
Mailing Address - Fax:
Practice Address - Street 1:147 LOMITA DR
Practice Address - Street 2:B
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-1451
Practice Address - Country:US
Practice Address - Phone:415-225-5285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10104171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist