Individual
CHARLES WARREN LACKEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
822 W 4TH ST, LEADVILLE, CO 80461-3861
(719) 486-1264
Mailing address
822 W 4TH ST, LEADVILLE, CO 80461-3861
(719) 486-1264
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
19438
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01194380
—
CO
Enumeration date
06/23/2005
Last updated
03/02/2023
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