Provider Demographics
NPI:1629701552
Name:MCCULLOCH, COLLIN ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:ROBERT
Last Name:MCCULLOCH
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 1:240 GALENA ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-1007
Mailing Address - Country:US
Mailing Address - Phone:608-370-6020
Mailing Address - Fax:
Practice Address - Street 1:240 GALENA ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-1007
Practice Address - Country:US
Practice Address - Phone:608-370-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6003-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor