Provider Demographics
NPI:1235563248
Name:KULLBERG, RICHARD ERICK
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ERICK
Last Name:KULLBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:ERICK
Other - Last Name:KULLBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LVN
Mailing Address - Street 1:3022 CAMULOS ST
Mailing Address - Street 2:#A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5527
Mailing Address - Country:US
Mailing Address - Phone:619-417-9634
Mailing Address - Fax:
Practice Address - Street 1:4126 1/2 36TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-2307
Practice Address - Country:US
Practice Address - Phone:619-417-9634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN153038164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse