Healthcare Provider Details

I. General information

NPI: 1356545123
Provider Name (Legal Business Name): ADITI J SHAH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16326 GLEN ALDER CT
LA MIRADA CA
90638-6512
US

IV. Provider business mailing address

PO BOX 788
HEMET CA
92546-0788
US

V. Phone/Fax

Practice location:
  • Phone: 714-350-0339
  • Fax:
Mailing address:
  • Phone: 951-929-6260
  • Fax: 951-765-2855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0978884
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: