Basic Information
| Provider Information | |||||||||
| NPI: | 1558317032 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KULCHYCKI | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 CUMMINS DR STE D | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953586411 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 250 BON AIR RD | ||||||||
| Address2: | |||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949041702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159257000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 227828 | MA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | C54499 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.