Provider Demographics
NPI:1104084623
Name:BULLIS FAMILY MEDICAL
Entity type:Organization
Organization Name:BULLIS FAMILY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BAMBI
Authorized Official - Middle Name:L
Authorized Official - Last Name:NICKELBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-673-3737
Mailing Address - Street 1:248 N LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1258
Mailing Address - Country:US
Mailing Address - Phone:310-673-3737
Mailing Address - Fax:310-673-0248
Practice Address - Street 1:248 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1258
Practice Address - Country:US
Practice Address - Phone:310-673-3737
Practice Address - Fax:310-673-0248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46679207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW8158Medicare PIN