Healthcare Provider Details

I. General information

NPI: 1306991062
Provider Name (Legal Business Name): CELIA ELAINE KULDA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11611 SAN VICENTE BLVD STE 500
LOS ANGELES CA
90049
US

IV. Provider business mailing address

12460 BAY HILL CT
GARDEN GROVE CA
92843-4182
US

V. Phone/Fax

Practice location:
  • Phone: 310-893-2319
  • Fax:
Mailing address:
  • Phone: 909-633-0362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9304TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: