MEDICARE: MR. TRACY SCOTT MACCALLUM LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	1462	NM
2	174400000X	Specialist	MT007176	TX

General Provider Information

NPI Number	:	1780709899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TRACY SCOTT MACCALLUM LMT

Provider Business Mailing Address
First Line	:	813 NAVAJO DR
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92507-6048
Country	:	US
Telephone Number	:	951-347-5179
Fax Number	:	951-779-9541

Provider Business Practice Location Address
First Line	:	6926 BROCKTON AVE
Second Line	:	#8
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3804
Country	:	US
Telephone Number	:	951-347-5179
Fax Number	:	951-779-9541

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	09/11/2025

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