Provider Demographics
NPI:1437314283
Name:MCCALLUM, JOHN RONALD CAMPBELL (LMT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RONALD CAMPBELL
Last Name:MCCALLUM
Suffix:
Gender:M
Credentials: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 733
Mailing Address - Street 2:
Mailing Address - City:STEVENSON
Mailing Address - State:WA
Mailing Address - Zip Code:98648-0733
Mailing Address - Country:US
Mailing Address - Phone:503-380-6195
Mailing Address - Fax:
Practice Address - Street 1:96 NW COLUMBIA AVE.
Practice Address - Street 2:
Practice Address - City:STEVENSON
Practice Address - State:WA
Practice Address - Zip Code:98648
Practice Address - Country:US
Practice Address - Phone:509-427-8203
Practice Address - Fax:509-427-4246
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015294173C00000X
OR11506173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist