Provider Demographics
NPI:1477901544
Name:CULLY, BLAINE
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:
Last Name:CULLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 NATHANIEL PL
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2735
Mailing Address - Country:US
Mailing Address - Phone:201-568-5968
Mailing Address - Fax:
Practice Address - Street 1:17 NATHANIEL PL
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2735
Practice Address - Country:US
Practice Address - Phone:201-568-5968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00735900111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition