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General NPI Number Information
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NPI Number | 1285804286
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Entity Type | Organization
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Legal Business Name | MCCULLOUGH EYECARE, PC
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Dates
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Enumeration Date | 03/05/2008
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Last Update Date | 07/05/2012
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Provider Practice Location Address
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Address Line | 202 WALNUT ST
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City | FESTUS
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State | MO
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Zip | 63028-1850
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Country | US
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Telephone | 636-937-3130
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Fax | 636-937-7202
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Provider Business Mailing Address
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Address Line | 202 WALNUT ST
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City | FESTUS
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State | MO
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Zip | 63028-1850
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Country | US
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Telephone | 636-937-3130
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Fax | 636-937-7202
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Authorized Official
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Title or Position | OWNER/OPTOMETRIST
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Name | DR. JAROD LANCE MCCULLOUGH
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Credential | O.D.
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Telephone | 636-937-3130
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2002014341
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License Number State | MO
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