Healthcare Provider Details

I. General information

NPI: 1467705889
Provider Name (Legal Business Name): MORGAN DOMINIQUE KNITTEL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 COURT ST STE 5
JACKSON CA
95642-2154
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD STE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 209-257-7515
  • Fax: 209-257-7513
Mailing address:
  • Phone: 800-972-5547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1025361
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: