Healthcare Provider Details

I. General information

NPI: 1851132625
Provider Name (Legal Business Name): BRENDA AVALOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 ALTURAS RD
FALLBROOK CA
92028-3197
US

IV. Provider business mailing address

483 SHADY GLEN DR
FALLBROOK CA
92028-2705
US

V. Phone/Fax

Practice location:
  • Phone: 760-405-6812
  • Fax:
Mailing address:
  • Phone: 760-405-6812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: