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General NPI Number Information
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NPI Number | 1790859585
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Entity Type | Organization
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Legal Business Name | JACK G MCCULLOCH JR
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Dates
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Enumeration Date | 11/20/2006
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Last Update Date | 04/11/2013
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Provider Practice Location Address
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Address Line | 685 S BREA BLVD
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City | BREA
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State | CA
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Zip | 92821-5308
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Country | US
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Telephone | 714-529-6399
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Fax | 714-529-2859
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Provider Business Mailing Address
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Address Line | 685 S BREA BLVD
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City | BREA
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State | CA
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Zip | 92821-5308
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Country | US
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Telephone | 714-529-6399
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Fax | 714-529-2859
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Authorized Official
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Title or Position | CO-OWNER
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Name | MRS. APRYL H MCCULLOCH
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Credential | C.PED.
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Telephone | 714-529-6399
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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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