MEDICARE: CIDNEY OVERLY 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	86290663	CA

General Provider Information

NPI Number	:	1790475903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CIDNEY OVERLY RD

Provider Business Mailing Address
First Line	:	6677 SANTA MONICA BLVD APT 3713
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90038-1690
Country	:	US
Telephone Number	:	925-548-3475
Fax Number	:

Provider Business Practice Location Address
First Line	:	6677 SANTA MONICA BLVD APT 3713
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90038-1690
Country	:	US
Telephone Number	:	925-548-3475
Fax Number	:

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

Provider Enumeration Date	:	05/10/2023
Last Update Date	:	05/10/2023

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Directions to “ CIDNEY OVERLY RD” Practice Location

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