Provider Demographics
NPI:1457863821
Name:MACALL, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:MACALL
Suffix:
Gender:F
Credentials:
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 1024
Mailing Address - Street 2:
Mailing Address - City:LUCERNE
Mailing Address - State:CA
Mailing Address - Zip Code:95458-1024
Mailing Address - Country:US
Mailing Address - Phone:707-274-9101
Mailing Address - Fax:
Practice Address - Street 1:6302 THIRTEENTH AVE
Practice Address - Street 2:
Practice Address - City:LUCERNE
Practice Address - State:CA
Practice Address - Zip Code:95458
Practice Address - Country:US
Practice Address - Phone:707-274-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA946000825Medicaid