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Organization
STUDENT
Active
Organization
STUDENT
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CULLEN MACK (STUDENT)
(951) 756-8989
Entity
Organization
Contact information
Practice address
1640 JUANITA LN, REDLANDS, CA 92373-7142
(951) 756-8989
Mailing address
1640 JUANITA LN, REDLANDS, CA 92373-7142
(951) 756-8989
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Enumeration date
08/28/2016
Last updated
08/28/2016
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