MEDICARE: CULLEN FERDARKO

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	111N00000X	Chiropractor	0008365	CO

General Provider Information

NPI Number	:	1902474182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CULLEN FERDARKO

Provider Business Mailing Address
First Line	:	1048 21 RD
Second Line	:
City	:	FRUITA
State	:	CO
Zip	:	81521-9319
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2412 PATTERSON RD STE 5
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81505-1259
Country	:	US
Telephone Number	:	717-935-5916
Fax Number	:

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

Provider Enumeration Date	:	06/15/2021
Last Update Date	:	06/15/2021

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