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General NPI Number Information
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NPI Number | 1104084623
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Entity Type | Organization
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Legal Business Name | BULLIS FAMILY MEDICAL
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Dates
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Enumeration Date | 05/30/2008
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Last Update Date | 06/02/2008
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Provider Practice Location Address
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Address Line | 248 N LOCUST ST
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City | INGLEWOOD
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State | CA
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Zip | 90301-1258
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Country | US
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Telephone | 310-673-3737
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Fax | 310-673-0248
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Provider Business Mailing Address
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Address Line | 248 N LOCUST ST
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City | INGLEWOOD
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State | CA
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Zip | 90301-1258
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Country | US
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Telephone | 310-673-3737
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Fax | 310-673-0248
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. BAMBI L. NICKELBERRY
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Credential | M.D.
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Telephone | 310-673-3737
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | G46679
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License Number State | CA
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