Healthcare Provider Details

I. General information

NPI: 1134664642
Provider Name (Legal Business Name): KARL CUA RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 W IMPERIAL HWY STE 220
BREA CA
92821-3812
US

IV. Provider business mailing address

290 MACALESTER DR
WALNUT CA
91789-2324
US

V. Phone/Fax

Practice location:
  • Phone: 714-618-9500
  • Fax:
Mailing address:
  • Phone: 909-594-3557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number912858
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: