Healthcare Provider Details

I. General information

NPI: 1467150862
Provider Name (Legal Business Name): CHARLOTTE HARGRAVE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 W IMPERIAL HWY STE 220
BREA CA
92821-3812
US

IV. Provider business mailing address

955 W IMPERIAL HWY STE 220
BREA CA
92821-3812
US

V. Phone/Fax

Practice location:
  • Phone: 714-618-9500
  • Fax:
Mailing address:
  • Phone: 714-618-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number86067066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: