Provider Demographics
NPI:1710190350
Name:ADULT & PEDIATRIC UROLOGY, LLC
Entity type:Organization
Organization Name:ADULT & PEDIATRIC UROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCCULLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-327-9111
Mailing Address - Street 1:2300 E 30TH ST
Mailing Address - Street 2:BLDG B SUITE 106
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8990
Mailing Address - Country:US
Mailing Address - Phone:505-327-9111
Mailing Address - Fax:505-327-2730
Practice Address - Street 1:2300 E 30TH ST
Practice Address - Street 2:BLDG B SUITE 106
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-327-9111
Practice Address - Fax:505-327-2730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM87115208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty