Provider Demographics
NPI:1356689285
Name:CAVALLO, CHARLIE (LAC)
Entity Type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:CAVALLO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 NE STANTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3117
Mailing Address - Country:US
Mailing Address - Phone:503-929-6416
Mailing Address - Fax:
Practice Address - Street 1:6008 AROSA ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-3809
Practice Address - Country:US
Practice Address - Phone:503-929-6416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16249225700000X
CA18998171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18998OtherCALIFORNIA STATE ACUPUNCTURE LICENSE