Provider Demographics
NPI:1255735627
Name:CALLAN, KAYLEIGH L (LAC)
Entity type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:L
Last Name:CALLAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 GLEN RD
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-3114
Mailing Address - Country:US
Mailing Address - Phone:973-453-5558
Mailing Address - Fax:
Practice Address - Street 1:471 GLEN RD
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-3114
Practice Address - Country:US
Practice Address - Phone:973-453-5558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00095600171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ81-2429761OtherEIN NUMBER