Provider Demographics
NPI:1134406762
Name:MCCULLOM, LORI GAINES (OTR)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:GAINES
Last Name:MCCULLOM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 E LINDSLEY RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-1023
Mailing Address - Country:US
Mailing Address - Phone:973-256-7220
Mailing Address - Fax:973-256-4723
Practice Address - Street 1:25 E LINDSLEY RD
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:NJ
Practice Address - Zip Code:07009-1023
Practice Address - Country:US
Practice Address - Phone:973-256-7220
Practice Address - Fax:973-256-4723
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00355900314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ315036Medicare Oscar/Certification