Healthcare Provider Details

I. General information

NPI: 1083795231
Provider Name (Legal Business Name): MAGNOLIA VELA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6285 E SPRING ST # 284
LONG BEACH CA
90808-4020
US

IV. Provider business mailing address

6285 E SPRING ST # 284
LONG BEACH CA
90808-4020
US

V. Phone/Fax

Practice location:
  • Phone: 562-424-4055
  • Fax: 949-577-4880
Mailing address:
  • Phone: 562-424-4055
  • Fax: 949-577-4880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberMNT894684
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberMNT894684
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberMNT894684
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberMNT894684
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: