Healthcare Provider Details

I. General information

NPI: 1164935409
Provider Name (Legal Business Name): ANDREA MARINCOVICH R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 01/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3833 WORSHAM AVE STE 300
LONG BEACH CA
90808-1766
US

IV. Provider business mailing address

3833 WORSHAM AVENUE SUITE 300
LONG BEACH CA
90808-1745
US

V. Phone/Fax

Practice location:
  • Phone: 562-595-5421
  • Fax: 562-426-2862
Mailing address:
  • Phone: 562-595-5421
  • Fax: 562-997-0754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86071266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: