Provider Demographics
NPI:1649481656
Name:CULLEN, MYRON JACOB (ATC)
Entity type:Individual
Prefix:MR
First Name:MYRON
Middle Name:JACOB
Last Name:CULLEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 RIVERSIDE PARK RD
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5385
Mailing Address - Country:US
Mailing Address - Phone:701-258-4415
Mailing Address - Fax:
Practice Address - Street 1:310 NTH 9TH STREET
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58506-5510
Practice Address - Country:US
Practice Address - Phone:701-530-8100
Practice Address - Fax:701-530-8160
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND07842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer