Provider Demographics
NPI:1760477814
Name:MCCULLOCH, ALEX A (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:ALEX
Middle Name:A
Last Name:MCCULLOCH
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 470066
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76147-0066
Mailing Address - Country:US
Mailing Address - Phone:817-896-2063
Mailing Address - Fax:817-731-7364
Practice Address - Street 1:3857 WASHBURN AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-3954
Practice Address - Country:US
Practice Address - Phone:817-732-8050
Practice Address - Fax:817-731-7364
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT18332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer