Provider Demographics
NPI:1265560338
Name:CONRAD, SCULLA O (C PED)
Entity type:Individual
Prefix:
First Name:SCULLA
Middle Name:O
Last Name:CONRAD
Suffix:
Gender:F
Credentials:C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1553 S NOVATO BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4112
Mailing Address - Country:US
Mailing Address - Phone:415-892-5788
Mailing Address - Fax:415-898-0852
Practice Address - Street 1:1553 S NOVATO BLVD STE D
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-4112
Practice Address - Country:US
Practice Address - Phone:415-892-5788
Practice Address - Fax:415-898-0852
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2196222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4145490001Medicare NSC