Healthcare Provider Details

I. General information

NPI: 1184027898
Provider Name (Legal Business Name): CHANEL NICOLE SUARES R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UCLA MEDICAL PLAZA SUITE 265
LOS ANGELES CA
90074-6114
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-301-8860
  • Fax:
Mailing address:
  • Phone: 310-301-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number86029129
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86029129
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: