Healthcare Provider Details

I. General information

NPI: 1376906594
Provider Name (Legal Business Name): KELSEA JOHANNA CREGUT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELSEA PALACE

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MOBIL AVE STE D27
CAMARILLO CA
93010-6338
US

IV. Provider business mailing address

5709 CHERRY RIDGE DR
CAMARILLO CA
93012-5515
US

V. Phone/Fax

Practice location:
  • Phone: 805-444-5919
  • Fax: 805-830-1735
Mailing address:
  • Phone: 805-444-5919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1036705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: