Provider Demographics
NPI:1134664642
Name:CUA, KARL
Entity Type:Individual
Prefix:MR
First Name:KARL
Middle Name:
Last Name:CUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 MACALESTER DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2324
Mailing Address - Country:US
Mailing Address - Phone:909-594-3557
Mailing Address - Fax:
Practice Address - Street 1:250 S G ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3320
Practice Address - Country:US
Practice Address - Phone:909-382-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL912858133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered