Provider Demographics
NPI:1376903690
Name:MACCULLOCH, MARCELLE (LAC)
Entity Type:Individual
Prefix:MS
First Name:MARCELLE
Middle Name:
Last Name:MACCULLOCH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 EDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-3132
Mailing Address - Country:US
Mailing Address - Phone:805-297-5172
Mailing Address - Fax:
Practice Address - Street 1:166 N MOORPARK RD
Practice Address - Street 2:SUITE 301
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4405
Practice Address - Country:US
Practice Address - Phone:805-491-5228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16896171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist