Healthcare Provider Details

I. General information

NPI: 1720761208
Provider Name (Legal Business Name): CALLUM LAVOIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

1137 N CENTRAL AVE APT 1520
GLENDALE CA
91202-3683
US

V. Phone/Fax

Practice location:
  • Phone: 780-717-2622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA188417
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberA188417
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: