Provider Demographics
NPI:1629379490
Name:MCCULLOUGH, STEVEN GLENN (COLO)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:GLENN
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:COLO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 N GREEN ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6458
Mailing Address - Country:US
Mailing Address - Phone:903-234-9300
Mailing Address - Fax:903-234-8704
Practice Address - Street 1:422 N GREEN ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6458
Practice Address - Country:US
Practice Address - Phone:903-234-9300
Practice Address - Fax:903-234-8704
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101239335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier