Provider Demographics
NPI:1770644916
Name:DR KIA VANDUSEN MCCULLEN DC PA
Entity Type:Organization
Organization Name:DR KIA VANDUSEN MCCULLEN DC PA
Other - Org Name:GENTLE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-744-8787
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4654111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
70732OtherBLUE CROSS BLUE SHIELD
FL381858600Medicaid
FL70732AMedicare PIN
FLT85496Medicare UPIN