Healthcare Provider Details

I. General information

NPI: 1508966284
Provider Name (Legal Business Name): TRACY L TAYLOR RD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2006
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2433 CENTRAL AVE STE A
ALAMEDA CA
94501-4564
US

IV. Provider business mailing address

815 MARIN RD
EL SOBRANTE CA
94803-1321
US

V. Phone/Fax

Practice location:
  • Phone: 510-521-2300
  • Fax: 510-974-8322
Mailing address:
  • Phone: 510-334-5097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: