Healthcare Provider Details

I. General information

NPI: 1124330980
Provider Name (Legal Business Name): DORA SEQUEIRA RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 CAMPUS DR SUITE 115
NEWPORT BEACH CA
92660-1815
US

IV. Provider business mailing address

50 WHITE SAGE
IRVINE CA
92618-8803
US

V. Phone/Fax

Practice location:
  • Phone: 949-874-3438
  • Fax: 866-372-1190
Mailing address:
  • Phone: 949-387-0885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number912967
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: