Healthcare Provider Details

I. General information

NPI: 1346527272
Provider Name (Legal Business Name): COLLETTE R. VIRDEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2011
Last Update Date: 11/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2213 ARABIAN WAY
CORONA CA
92879-7907
US

IV. Provider business mailing address

2213 ARABIAN WAY
CORONA CA
92879-7907
US

V. Phone/Fax

Practice location:
  • Phone: 909-363-6521
  • Fax:
Mailing address:
  • Phone: 909-363-6521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: