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General NPI Number Information
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NPI Number | 1770875924
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Entity Type | Individual
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Provider Name | COLIN ALEXANDER MCCULLOUGH A.T.C., C.S.C.S.
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Gender | Male
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Dates
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Enumeration Date | 05/06/2011
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Last Update Date | 05/06/2011
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Provider Practice Location Address
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Address Line | 140 COMMONWEALTH AVE YAWKEY CENTER- ROOM 108
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City | CHESTNUT HILL
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State | MA
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Zip | 02467-3800
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Country | US
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Telephone | 617-552-9113
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Fax | 617-552-9101
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Provider Business Mailing Address
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Address Line | 41 STRATHMORE RD APT 6
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City | BRIGHTON
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State | MA
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Zip | 02135-7935
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Country | US
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Telephone | 413-329-6826
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2096
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License Number State | MA
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