Provider Demographics
NPI:1457852105
Name:BRANDY NICOLE MCCULLOUCH
Entity Type:Organization
Organization Name:BRANDY NICOLE MCCULLOUCH
Other - Org Name:BRANDY NICOLE MCCULLOUCH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-717-8705
Mailing Address - Street 1:708 COWBOY CROSS AVE
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6746
Mailing Address - Country:US
Mailing Address - Phone:702-717-8705
Mailing Address - Fax:
Practice Address - Street 1:708 COWBOY CROSS AVE
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-6746
Practice Address - Country:US
Practice Address - Phone:702-717-8705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty