Provider Demographics
NPI:1851580831
Name:MCCULLOUGH VARGAS AND ASSOCIATES INC
Entity Type:Organization
Organization Name:MCCULLOUGH VARGAS AND ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:N
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CAADC
Authorized Official - Phone:517-849-2330
Mailing Address - Street 1:110 READING AVE
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49250-1136
Mailing Address - Country:US
Mailing Address - Phone:517-849-2330
Mailing Address - Fax:517-849-2906
Practice Address - Street 1:110 READING AVE
Practice Address - Street 2:
Practice Address - City:JONESVILLE
Practice Address - State:MI
Practice Address - Zip Code:49250-1136
Practice Address - Country:US
Practice Address - Phone:517-849-2330
Practice Address - Fax:517-849-2906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI300027251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5602Medicare PIN