Provider Demographics
NPI:1407922487
Name:CULLEN, BRENT GREGORY (DC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:GREGORY
Last Name:CULLEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7276 LIBERTY WAY
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-1519
Mailing Address - Country:US
Mailing Address - Phone:513-365-2292
Mailing Address - Fax:513-759-3462
Practice Address - Street 1:7276 LIBERTY WAY
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-1519
Practice Address - Country:US
Practice Address - Phone:513-365-2292
Practice Address - Fax:513-759-3462
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3380111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2798914Medicaid
OH3031696Medicaid
V05604Medicare UPIN
CU4163001Medicare ID - Type Unspecified
OH2798914Medicaid