Provider Demographics
NPI:1477733962
Name:SULIS, DAVID STEVEN (CPO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:STEVEN
Last Name:SULIS
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3714 TIBBETTS ST.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3020
Mailing Address - Country:US
Mailing Address - Phone:951-367-6702
Mailing Address - Fax:951-367-7789
Practice Address - Street 1:3714 TIBBETTS ST
Practice Address - Street 2:SUITE 104
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2661
Practice Address - Country:US
Practice Address - Phone:951-367-6702
Practice Address - Fax:951-367-7789
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC22175332BC3200X
CACP002649335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXA0029550Medicaid
CACMS168487OtherCCS
CA5235110001Medicare NSC