Provider Demographics
NPI:1447744156
Name:CULLINS, CLINTON (LDN)
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:CULLINS
Suffix:
Gender:M
Credentials:LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E HAWTHORN PKWY STE 235
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1454
Mailing Address - Country:US
Mailing Address - Phone:847-737-8768
Mailing Address - Fax:
Practice Address - Street 1:1859 S TOPAZ WAY STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4401
Practice Address - Country:US
Practice Address - Phone:208-209-2432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1039133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered