Provider Demographics
NPI:1235450750
Name:MCCULLOUGH, MELVIN
Entity Type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:
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 1:1467 EBENEZER RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-2338
Mailing Address - Country:US
Mailing Address - Phone:803-980-8822
Mailing Address - Fax:
Practice Address - Street 1:1467 EBENEZER RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2338
Practice Address - Country:US
Practice Address - Phone:803-980-8822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9451225700000X
SC6643225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist