Provider Demographics
NPI:1790859585
Name:JACK G MCCULLOCH JR
Entity Type:Organization
Organization Name:JACK G MCCULLOCH JR
Other - Org Name:MCCULLOCH'S WIDE SHOES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:APRYL
Authorized Official - Middle Name:H
Authorized Official - Last Name:MCCULLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:714-529-6399
Mailing Address - Street 1:685 S BREA BLVD
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5308
Mailing Address - Country:US
Mailing Address - Phone:714-529-6399
Mailing Address - Fax:714-529-2859
Practice Address - Street 1:685 S BREA BLVD
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5308
Practice Address - Country:US
Practice Address - Phone:714-529-6399
Practice Address - Fax:714-529-2859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4808450001Medicare NSC