Healthcare Provider Details

I. General information

NPI: 1750913778
Provider Name (Legal Business Name): LAURIE ANN SCOPPETTO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

482 N AVIATION BLVD
EL SEGUNDO CA
90245
US

IV. Provider business mailing address

733 30TH ST
HERMOSA BEACH CA
90254-2213
US

V. Phone/Fax

Practice location:
  • Phone: 310-653-1110
  • Fax:
Mailing address:
  • Phone: 860-918-1404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86143976
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: