MEDICARE: JOHN C. CULLEN CADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	242	OK

General Provider Information

NPI Number	:	1144432972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN C. CULLEN CADC

Provider Business Mailing Address
First Line	:	PO BOX 6012
Second Line	:
City	:	NORMAN
State	:	OK
Zip	:	73070-6012
Country	:	US
Telephone Number	:	405-810-1766
Fax Number	:	405-810-0331

Provider Business Practice Location Address
First Line	:	5208 CLASSEN CIR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-4429
Country	:	US
Telephone Number	:	405-810-1766
Fax Number	:	405-810-0331

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	07/08/2007

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