MEDICARE: KEVIN CULLEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service	0041750	CA

General Provider Information

NPI Number	:	1407103567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN CULLEN

Provider Business Mailing Address
First Line	:	3419 VIA LIDO
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-3908
Country	:	US
Telephone Number	:	949-723-2388
Fax Number	:	949-723-1288

Provider Business Practice Location Address
First Line	:	3206 W BALBOA BLVD
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-3018
Country	:	US
Telephone Number	:	949-723-2388
Fax Number	:	949-723-1288

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2012
Last Update Date	:	08/08/2012

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Directions to “ KEVIN CULLEN ” Practice Location

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