MEDICARE: GRACE TESSA MCGUIRK 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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1740938802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE TESSA MCGUIRK RD

Provider Business Mailing Address
First Line	:	2271 EMERALD ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-3746
Country	:	US
Telephone Number	:	201-914-2709
Fax Number	:

Provider Business Practice Location Address
First Line	:	2271 EMERALD ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-3746
Country	:	US
Telephone Number	:	201-914-2709
Fax Number	:

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

Provider Enumeration Date	:	03/16/2022
Last Update Date	:	03/16/2022

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