Provider Demographics
NPI:1588739130
Name:LISA MICHELLE CALLAHAN
Entity type:Organization
Organization Name:LISA MICHELLE CALLAHAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:541-472-0021
Mailing Address - Street 1:1601 NE 6TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1035
Mailing Address - Country:US
Mailing Address - Phone:541-472-0021
Mailing Address - Fax:541-476-4003
Practice Address - Street 1:1601 NE 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1035
Practice Address - Country:US
Practice Address - Phone:541-476-3636
Practice Address - Fax:541-474-4628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR94000382N2261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care