Provider Demographics
NPI:1053415166
Name:MCCULLOUGH, MICHAEL WARREN (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WARREN
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6003 OVERLAND RD STE 104
Mailing Address - Street 2:STE 104
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709
Mailing Address - Country:US
Mailing Address - Phone:208-343-2771
Mailing Address - Fax:208-321-7914
Practice Address - Street 1:6003 OVERLAND RD STE 104
Practice Address - Street 2:STE 104
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-343-2771
Practice Address - Fax:208-321-7914
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC516111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0012215Medicaid
IDC5162OtherBLUE CROSS
1672183Medicare ID - Type Unspecified
IDC5162OtherBLUE CROSS