Provider Demographics
NPI:1356689285
Name:CAVALLO, CHARLIE (LAC)
Entity type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:CAVALLO
Suffix:
Gender:
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 TIERRA NUEVA LN
Mailing Address - Street 2:
Mailing Address - City:OCEANO
Mailing Address - State:CA
Mailing Address - Zip Code:93445-9126
Mailing Address - Country:US
Mailing Address - Phone:503-929-6416
Mailing Address - Fax:
Practice Address - Street 1:1325 CHORRO ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4005
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:2025-02-25
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