Provider Demographics
NPI:1861514960
Name:MCCULLOUGH, IAN (LAC)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 PITT AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3747
Mailing Address - Country:US
Mailing Address - Phone:707-823-4300
Mailing Address - Fax:707-634-1762
Practice Address - Street 1:490 PITT AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3747
Practice Address - Country:US
Practice Address - Phone:707-823-4300
Practice Address - Fax:707-634-1762
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11262171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist