Healthcare Provider Details

I. General information

NPI: 1447427455
Provider Name (Legal Business Name): CARLY DENISE MAITLEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 SIERRA AVE FOOD AND NUTRITION SERVICES
FONTANA CA
92335
US

IV. Provider business mailing address

6153 PERIDOT AVE
ALTA LOMA CA
91701
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-7185
  • Fax:
Mailing address:
  • Phone: 909-427-7185
  • Fax: 909-427-4151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number00966300
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: