Provider Demographics
NPI:1326306762
Name:CULLISON, KALEB BLAIR (PT DPT)
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:BLAIR
Last Name:CULLISON
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23100 EUCALYPTUS AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5439
Mailing Address - Country:US
Mailing Address - Phone:951-379-1500
Mailing Address - Fax:951-379-1501
Practice Address - Street 1:277 RANCHEROS DR STE 150
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2976
Practice Address - Country:US
Practice Address - Phone:951-379-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38863225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0293956OtherSTATE OF WASHINGTON DEPT. OF LABOR AND INDUSTRIES
CA0PT388630OtherBLUE SHIELD OF CALIFORNIA
CA0293956OtherSTATE OF WASHINGTON DEPT. OF LABOR AND INDUSTRIES
CACB238044Medicare PIN