MEDICARE: PATRICIA MIRANDA JARDACK RDN

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	133VN1006X	Metabolic Nutrition Registered Dietitian	872564	CA
2	133V00000X	Registered Dietitian	872564	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	872564	OTHER		RDN REGISTRATION

General Provider Information

NPI Number	:	1215406269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA MIRANDA JARDACK RDN

Provider Business Mailing Address
First Line	:	1930 OCEAN AVE APT 114
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-1040
Country	:	US
Telephone Number	:	310-382-7575
Fax Number	:

Provider Business Practice Location Address
First Line	:	10833 LE CONTE AVE
Second Line	:	37-075 CHS
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-1697
Country	:	US
Telephone Number	:	310-825-5768
Fax Number	:	310-267-1054

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

Provider Enumeration Date	:	11/20/2018
Last Update Date	:	11/20/2018

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