Healthcare Provider Details

I. General information

NPI: 1356576375
Provider Name (Legal Business Name): LYNNE ANN TRESTRAIL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 STANWELL DR STE C
CONCORD CA
94520-4841
US

IV. Provider business mailing address

2300 STANWELL DR STE C
CONCORD CA
94520-4841
US

V. Phone/Fax

Practice location:
  • Phone: 925-677-7492
  • Fax:
Mailing address:
  • Phone: 925-677-7492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number469157
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: