Healthcare Provider Details

I. General information

NPI: 1124280557
Provider Name (Legal Business Name): RENEE M. SODERQUIST RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E VALENCIA MESA DR SUITE 105
FULLERTON CA
92835-3813
US

IV. Provider business mailing address

100 E VALENCIA MESA DR SUITE 105
FULLERTON CA
92835-3813
US

V. Phone/Fax

Practice location:
  • Phone: 714-446-5640
  • Fax: 714-446-5625
Mailing address:
  • Phone: 714-446-5640
  • Fax: 714-446-5625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberR711364
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: