1356689285 NPI number — MR. CHARLIE CAVALLO LAC

Table of content: MR. CHARLIE CAVALLO LAC (NPI 1356689285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356689285 NPI number — MR. CHARLIE CAVALLO LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAVALLO
Provider First Name:
CHARLIE
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356689285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
614 NE STANTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97212-3117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-929-6416
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6008 AROSA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92115-3809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-929-6416
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  16249 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171100000X , with the licence number: 18998 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 18998 . This is a "CALIFORNIA STATE ACUPUNCTURE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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