Healthcare Provider Details

I. General information

NPI: 1922452705
Provider Name (Legal Business Name): MARY GRAHAM MCCULLOUGH D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 SAN PEDRO DR NE SUITE A
ALBUQUERQUE NM
87110-3326
US

IV. Provider business mailing address

2716 SAN PEDRO DR NE SUITE A
ALBUQUERQUE NM
87110-3326
US

V. Phone/Fax

Practice location:
  • Phone: 505-433-7472
  • Fax:
Mailing address:
  • Phone: 505-433-7472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1178
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: