Healthcare Provider Details

I. General information

NPI: 1780087833
Provider Name (Legal Business Name): JIN KUO RDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2014
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25885 TRABUCO RD. APT #120
LAKE FOREST CA
92630
US

IV. Provider business mailing address

25885 TRABUCO RD. APT #120
LAKE FOREST CA
92630
US

V. Phone/Fax

Practice location:
  • Phone: 949-241-5313
  • Fax:
Mailing address:
  • Phone: 949-241-5313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number979328
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: