Provider Demographics
NPI:1285804286
Name:MCCULLOUGH EYECARE, PC
Entity type:Organization
Organization Name:MCCULLOUGH EYECARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAROD
Authorized Official - Middle Name:LANCE
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:636-937-3130
Mailing Address - Street 1:202 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1850
Mailing Address - Country:US
Mailing Address - Phone:636-937-3130
Mailing Address - Fax:636-937-7202
Practice Address - Street 1:202 WALNUT ST
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1850
Practice Address - Country:US
Practice Address - Phone:636-937-3130
Practice Address - Fax:636-937-7202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002014341152W00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODP6365OtherPALMETTO GBA-RR MEDICARE
MO319118907Medicaid
MODP6365OtherPALMETTO GBA-RR MEDICARE
MO000025670Medicare PIN