Provider Demographics
NPI:1184223943
Name:MCCULLOUGH, QUINCY EUGENE
Entity Type:Individual
Prefix:MR
First Name:QUINCY
Middle Name:EUGENE
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15693 CHOCTAW ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5531
Mailing Address - Country:US
Mailing Address - Phone:442-229-2100
Mailing Address - Fax:442-229-2100
Practice Address - Street 1:15693 CHOCTAW ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5531
Practice Address - Country:US
Practice Address - Phone:442-229-2100
Practice Address - Fax:442-229-2100
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA361800175310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility