Healthcare Provider Details

I. General information

NPI: 1144253923
Provider Name (Legal Business Name): MCCULLOUGH, VARGAS, & ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 RIVERSIDE AVE STE 11
ADRIAN MI
49221-1476
US

IV. Provider business mailing address

770 RIVERSIDE AVE STE 11
ADRIAN MI
49221-1476
US

V. Phone/Fax

Practice location:
  • Phone: 517-264-2244
  • Fax: 517-263-3325
Mailing address:
  • Phone: 517-264-2244
  • Fax: 517-263-3325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number460036
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. GERALD MCCULLOUGH
Title or Position: EXECUTIVE DIRECTOR
Credential: MA, CAADC
Phone: 517-264-2244