Provider Demographics
NPI:1215978424
Name:STEVEN G MCCULLOUGH AND DAVID W HOLT ORTHOTICS & PROSTHETICS LLC
Entity type:Organization
Organization Name:STEVEN G MCCULLOUGH AND DAVID W HOLT ORTHOTICS & PROSTHETICS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-864-8783
Mailing Address - Street 1:102 WOODMONT BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-5249
Mailing Address - Country:US
Mailing Address - Phone:615-864-8790
Mailing Address - Fax:615-454-5352
Practice Address - Street 1:1120 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2109
Practice Address - Country:US
Practice Address - Phone:903-592-5900
Practice Address - Fax:903-592-6683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101171335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
519266OtherBCBS
TX087070101Medicaid
519266OtherBCBS