Healthcare Provider Details

I. General information

NPI: 1689462376
Provider Name (Legal Business Name): CHARLES LUCAS LAWALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 WALNUT ST STE 620
PHILADELPHIA PA
19107-5005
US

IV. Provider business mailing address

1001 CHESTNUT ST APT 502E
PHILADELPHIA PA
19107-4219
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-6864
  • Fax: 215-955-2878
Mailing address:
  • Phone: 267-454-8136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: