Healthcare Provider Details

I. General information

NPI: 1962224766
Provider Name (Legal Business Name): HAILEY MACKENZIE MCCULLUM PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HAILEY MACKENZIE HOPPER PTA

II. Dates (important events)

Enumeration Date: 10/31/2024
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17800 US HIGHWAY 18
APPLE VALLEY CA
92307-1221
US

IV. Provider business mailing address

12901 GALEWOOD ST
APPLE VALLEY CA
92308-6793
US

V. Phone/Fax

Practice location:
  • Phone: 760-646-8000
  • Fax:
Mailing address:
  • Phone: 760-694-7298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number49821
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number014806
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: