=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548407174
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCCULLOCH CHIROPRACTIC, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2009
-----------------------------------------------------
Last Update Date | 01/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 396 RED CEDAR ST
-----------------------------------------------------
City | MENOMONIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54751-2386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-231-2533
-----------------------------------------------------
Fax | 715-231-2534
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 396 RED CEDAR ST
-----------------------------------------------------
City | MENOMONIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54751-2386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-231-2533
-----------------------------------------------------
Fax | 715-231-2534
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. TIMOTHY SCOTT MCCULLOCH
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 715-231-2533
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3190-012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------