Provider Demographics
NPI:1184822793
Name:STEVEN G MCCULLOUGH AND DAVID W HOLT ORTHOTICS & PROSTHETICS, LLC
Entity Type:Organization
Organization Name:STEVEN G MCCULLOUGH AND DAVID W HOLT ORTHOTICS & PROSTHETICS, LLC
Other - Org Name:CUSTOM CARE ORTHOPEDIC BRACING AND PROSTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-864-8783
Mailing Address - Street 1:102 WOODMONT BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-5249
Mailing Address - Country:US
Mailing Address - Phone:615-864-8790
Mailing Address - Fax:615-454-5352
Practice Address - Street 1:422 N GREEN ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6458
Practice Address - Country:US
Practice Address - Phone:903-234-9300
Practice Address - Fax:903-234-8704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101171335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX284080301Medicaid
TX517688OtherO&P
TX284080303Medicaid
6922550001OtherDMEPOS MEDICARE PTAN