Provider Demographics
NPI:1629775499
Name:MCCULLOUGH, SHIR'MEL CANDIS
Entity Type:Individual
Prefix:
First Name:SHIR'MEL
Middle Name:CANDIS
Last Name:MCCULLOUGH
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 1:1601 GREENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29208-4001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:271 FT. RICHARDSON AVENUE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76908-4902
Practice Address - Country:US
Practice Address - Phone:325-654-3221
Practice Address - Fax:325-654-1161
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program