Healthcare Provider Details

I. General information

NPI: 1508249384
Provider Name (Legal Business Name): JESSIE FRAGOSO RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11812 JULIUS AVE
DOWNEY CA
90241-4612
US

IV. Provider business mailing address

13300 GARDEN GROVE BLVD
GARDEN GROVE CA
92843-2207
US

V. Phone/Fax

Practice location:
  • Phone: 562-659-4081
  • Fax:
Mailing address:
  • Phone: 562-659-4081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86045829
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: