MEDICARE: OLUTOSIN KIRYA DTR, CLT

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	136A00000X	Registered Dietetic Technician	86143459	CA

General Provider Information

NPI Number	:	1023507282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLUTOSIN KIRYA DTR, CLT

Provider Business Mailing Address
First Line	:	PO BOX 2867
Second Line	:
City	:	MISSION VIEJO
State	:	CA
Zip	:	92690-0867
Country	:	US
Telephone Number	:	949-614-6354
Fax Number	:

Provider Business Practice Location Address
First Line	:	31654 RANCHO VIEJO RD STE G
Second Line	:
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-2774
Country	:	US
Telephone Number	:	949-899-8361
Fax Number	:

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

Provider Enumeration Date	:	05/03/2018
Last Update Date	:	05/03/2018

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