Healthcare Provider Details

I. General information

NPI: 1689257123
Provider Name (Legal Business Name): SAVANNA ROOFF RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVE
MODESTO CA
95350-4404
US

IV. Provider business mailing address

7107 SHORELINE DR
STOCKTON CA
95219-5478
US

V. Phone/Fax

Practice location:
  • Phone: 209-578-1211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86156437
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: