Provider Demographics
NPI:1902498900
Name:CULLER, JERRYAL JR
Entity Type:Individual
Prefix:MR
First Name:JERRYAL
Middle Name:
Last Name:CULLER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-2531
Mailing Address - Country:US
Mailing Address - Phone:510-807-5090
Mailing Address - Fax:
Practice Address - Street 1:195 W 9TH ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-2531
Practice Address - Country:US
Practice Address - Phone:510-807-5090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD2264640343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)