Individual
MICHAEL WARREN MCCULLOUGH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DC
Contact information
Practice address
6003 OVERLAND RD STE 104, STE 104, BOISE, ID 83709
(208) 343-2771
(208) 321-7914
Mailing address
6003 OVERLAND RD STE 104, STE 104, BOISE, ID 83709
(208) 343-2771
(208) 321-7914
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
C516
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0012215
—
ID
01
—
C5162
BLUE CROSS
ID
Enumeration date
09/11/2006
Last updated
07/08/2007
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