Healthcare Provider Details

I. General information

NPI: 1619812203
Provider Name (Legal Business Name): KAELYN MINOR RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 W ATEN RD
IMPERIAL CA
92251-9818
US

IV. Provider business mailing address

435 W ATEN RD
IMPERIAL CA
92251-9818
US

V. Phone/Fax

Practice location:
  • Phone: 760-879-8590
  • Fax: 855-576-4802
Mailing address:
  • Phone: 760-879-8590
  • Fax: 855-576-4802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: