Provider Demographics
NPI:1598407819
Name:MCCULLOCK, JAMES MICHAEL (CMT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:MCCULLOCK
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4494 39TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4677
Mailing Address - Country:US
Mailing Address - Phone:619-902-2591
Mailing Address - Fax:
Practice Address - Street 1:4494 39TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-4677
Practice Address - Country:US
Practice Address - Phone:619-902-2591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88704225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist