Provider Demographics
NPI:1568523884
Name:MCCULLOUGH, JUDIT IBOLYA (DC)
Entity Type:Individual
Prefix:DR
First Name:JUDIT
Middle Name:IBOLYA
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S. ORCHARD ST.
Mailing Address - Street 2:SUITE 152
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705
Mailing Address - Country:US
Mailing Address - Phone:208-340-2555
Mailing Address - Fax:208-338-6590
Practice Address - Street 1:410 S. ORCHARD ST.
Practice Address - Street 2:SUITE 152
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705
Practice Address - Country:US
Practice Address - Phone:208-340-2555
Practice Address - Fax:208-338-6590
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1098111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU83944Medicare UPIN
ID1670406Medicare ID - Type Unspecified