Provider Demographics
NPI:1649397779
Name:RON MCCULLEY
Entity Type:Organization
Organization Name:RON MCCULLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-264-2424
Mailing Address - Street 1:2520 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63780-1219
Mailing Address - Country:US
Mailing Address - Phone:573-264-2424
Mailing Address - Fax:
Practice Address - Street 1:2520 JAMES ST
Practice Address - Street 2:
Practice Address - City:SCOTT CITY
Practice Address - State:MO
Practice Address - Zip Code:63780-1219
Practice Address - Country:US
Practice Address - Phone:573-264-2424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032088261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266796309Medicaid