Healthcare Provider Details

I. General information

NPI: 1760892947
Provider Name (Legal Business Name): HADIS GHOGHAIE REGISTERED DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 04/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 EMERALD ST
LOS ANGELES CA
90026-6105
US

IV. Provider business mailing address

251 EMERALD ST
LOS ANGELES CA
90026-6105
US

V. Phone/Fax

Practice location:
  • Phone: 646-201-3630
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1070544
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1070544
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1070544
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: