Provider Demographics
NPI:1154487734
Name:KULICK, ANDREW M (DC)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:M
Last Name:KULICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:MR
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:48 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-4318
Mailing Address - Country:US
Mailing Address - Phone:781-209-7241
Mailing Address - Fax:
Practice Address - Street 1:176 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-3129
Practice Address - Country:US
Practice Address - Phone:617-776-7576
Practice Address - Fax:617-825-5006
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1575111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician