Provider Demographics
NPI:1144253923
Name:MCCULLOUGH, VARGAS, & ASSOCIATES, INC.
Entity type:Organization
Organization Name:MCCULLOUGH, VARGAS, & ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CAADC
Authorized Official - Phone:517-264-2244
Mailing Address - Street 1:770 RIVERSIDE AVE
Mailing Address - Street 2:STE 11
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1476
Mailing Address - Country:US
Mailing Address - Phone:517-264-2244
Mailing Address - Fax:517-263-3325
Practice Address - Street 1:770 RIVERSIDE AVE
Practice Address - Street 2:STE 11
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1476
Practice Address - Country:US
Practice Address - Phone:517-264-2244
Practice Address - Fax:517-263-3325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI460036261QR0405X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5602Medicare PIN