MEDICARE: NAZILA NIKRAVESH RD

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	133NN1002X	Nutrition Education Nutritionist
2	133V00000X	Registered Dietitian	968744	CA
3	133VN1004X	Pediatric Nutrition Registered Dietitian
4	133VN1005X	Renal Nutrition Registered Dietitian	968744	CA
5	133VN1006X	Metabolic Nutrition Registered Dietitian

General Provider Information

NPI Number	:	1326343328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NAZILA NIKRAVESH RD

Provider Business Mailing Address
First Line	:	1114 S SHERBOURNE DR APT 7
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-2335
Country	:	US
Telephone Number	:	310-666-9792
Fax Number	:

Provider Business Practice Location Address
First Line	:	1114 SOUTH SHERBOURNE # 7
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035
Country	:	US
Telephone Number	:	310-666-9792
Fax Number	:

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

Provider Enumeration Date	:	01/21/2011
Last Update Date	:	01/21/2011

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