1962507533 NPI number — MS. CAROL DENISE MCCULLEY CERT ADDICTIONS SPEC

Table of content: MS. CAROL DENISE MCCULLEY CERT ADDICTIONS SPEC (NPI 1962507533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962507533 NPI number — MS. CAROL DENISE MCCULLEY CERT ADDICTIONS SPEC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCULLEY
Provider First Name:
CAROL
Provider Middle Name:
DENISE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CERT ADDICTIONS SPEC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BORN
Provider Other First Name:
CAROL
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962507533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1374
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTURAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-233-4209
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
441 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTURAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-233-6319
Provider Business Practice Location Address Fax Number:
530-233-5311
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  03026319 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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