Provider Demographics
NPI:1497871214
Name:MELISSA J MCCULLEY O D P C
Entity Type:Organization
Organization Name:MELISSA J MCCULLEY O D P C
Other - Org Name:MCCULLEY OPTIX GALLERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCCULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-373-2020
Mailing Address - Street 1:567 32ND AVE E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8480
Mailing Address - Country:US
Mailing Address - Phone:701-373-2020
Mailing Address - Fax:701-373-0021
Practice Address - Street 1:567 32ND AVE E
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-8480
Practice Address - Country:US
Practice Address - Phone:701-373-2020
Practice Address - Fax:701-373-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND597152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND06711001OtherBLUE SHIELD GROUP NUMBER
MN88G74MCOtherBLUE SHIELD
ND06711001OtherBLUE SHIELD GROUP NUMBER
ND711749Medicare ID - Type Unspecified