Provider Demographics
NPI:1932363751
Name:STEVEN G MCCULLOUGH
Entity Type:Organization
Organization Name:STEVEN G MCCULLOUGH
Other - Org Name:CUSTOM CARE ORTHOPEDIC BRACING LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED ORTHOTIST
Authorized Official - Phone:903-592-5900
Mailing Address - Street 1:1110 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2109
Mailing Address - Country:US
Mailing Address - Phone:903-592-5900
Mailing Address - Fax:903-592-6683
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:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101171335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX087070101Medicaid
TX5495030001Medicare NSC