Provider Demographics
NPI:1679634828
Name:MCCULLEN, KIA (DC)
Entity Type:Individual
Prefix:
First Name:KIA
Middle Name:
Last Name:MCCULLEN
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 1:1264 COUNTY ROAD 1
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-4610
Mailing Address - Country:US
Mailing Address - Phone:727-744-8787
Mailing Address - Fax:727-738-5888
Practice Address - Street 1:1264 COUNTY ROAD 1
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-4610
Practice Address - Country:US
Practice Address - Phone:727-744-8787
Practice Address - Fax:727-738-5888
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4654111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381858600Medicaid
FL70732OtherBLUE CROSS-BLUE SHIELD
FLT85496Medicare UPIN
FL70732AMedicare PIN