Healthcare Provider Details

I. General information

NPI: 1629259049
Provider Name (Legal Business Name): STEPHEN B CALLIS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 JANET LN
VERNON CT
06066-3512
US

IV. Provider business mailing address

PO BOX 3145
VERNON CT
06066-2045
US

V. Phone/Fax

Practice location:
  • Phone: 860-966-8204
  • Fax: 860-896-1383
Mailing address:
  • Phone: 860-966-8204
  • Fax: 860-896-1383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number004705
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: