Healthcare Provider Details

I. General information

NPI: 1053041574
Provider Name (Legal Business Name): MARY KATHRIN DUBOIS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 E WASHINGTON BLVD STE 100
COMMERCE CA
90040-2451
US

IV. Provider business mailing address

34162 CAPISTRANO BY THE SEA
DANA POINT CA
92629-2940
US

V. Phone/Fax

Practice location:
  • Phone: 562-928-9600
  • Fax:
Mailing address:
  • Phone: 194-924-0433
  • Fax: 949-240-4392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number722761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: