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General NPI Number Information
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NPI Number | 1710190350
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Entity Type | Organization
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Legal Business Name | ADULT & PEDIATRIC UROLOGY, LLC
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2300 E 30TH ST BLDG B SUITE 106
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City | FARMINGTON
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State | NM
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Zip | 87401-8990
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Country | US
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Telephone | 505-327-9111
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Fax | 505-327-2730
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Provider Business Mailing Address
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Address Line | 2300 E 30TH ST BLDG B SUITE 106
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City | FARMINGTON
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State | NM
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Zip | 87401-8990
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Country | US
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Telephone | 505-327-9111
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Fax | 505-327-2730
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Authorized Official
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Title or Position | OWNER
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Name | DR. ALLEN W MCCULLOCH
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Credential | M.D.
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Telephone | 505-327-9111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 87115
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License Number State | NM
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