Basic Information
| Provider Information | |||||||||
| NPI: | 1326306762 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CULLISON | ||||||||
| FirstName: | KALEB | ||||||||
| MiddleName: | BLAIR | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 CENTRAL AVE STE C | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925302749 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 255 N ELM ST | ||||||||
| Address2: | STE. 202 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920253431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7605040223 | ||||||||
| FaxNumber: | 7605040224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2012 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 38863 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0293956 | 01 | CA | STATE OF WASHINGTON DEPT. OF LABOR AND INDUSTRIES | OTHER | 0PT388630 | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER |