Healthcare Provider Details

I. General information

NPI: 1134065667
Provider Name (Legal Business Name): MARTELL MCCULLOUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2913 VIENNA MILL CT SW
CANTON OH
44706-5635
US

IV. Provider business mailing address

2913 VIENNA MILL CT SW
CANTON OH
44706-5635
US

V. Phone/Fax

Practice location:
  • Phone: 330-639-6460
  • Fax:
Mailing address:
  • Phone: 330-639-6460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number74981229
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: