Healthcare Provider Details

I. General information

NPI: 1508473695
Provider Name (Legal Business Name): JOSIAH MICHAEL CUCKLER RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 09/23/2020
Certification Date: 09/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 HIDDEN VALLEY RD
MONROVIA CA
91016-1601
US

IV. Provider business mailing address

45 HIDDEN VALLEY RD
MONROVIA CA
91016-1601
US

V. Phone/Fax

Practice location:
  • Phone: 970-581-1206
  • Fax:
Mailing address:
  • Phone: 970-581-1206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86145628
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: