Provider Demographics
NPI:1962705137
Name:MCCALLUM, ROSS (LAC)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:MCCALLUM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16099 SE MCLOUGHLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-4680
Mailing Address - Country:US
Mailing Address - Phone:503-894-8803
Mailing Address - Fax:503-922-1129
Practice Address - Street 1:16099 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-4680
Practice Address - Country:US
Practice Address - Phone:503-894-8803
Practice Address - Fax:503-922-1129
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-10
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR126276171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist