Healthcare Provider Details

I. General information

NPI: 1407243686
Provider Name (Legal Business Name): KIMBERLY SPEROS RD CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W THOMAS RD FOOD & NUTRITION DEPARTMENT
PHOENIX AZ
85013-4409
US

IV. Provider business mailing address

1210 E NORTHERN AVE
PHOENIX AZ
85020-4217
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-3115
  • Fax: 602-406-6660
Mailing address:
  • Phone: 602-677-4164
  • Fax: 602-532-7146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number11002
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: