Healthcare Provider Details

I. General information

NPI: 1285452334
Provider Name (Legal Business Name): MARY CRIS MONSANTO LEBIG MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 VISTA WAY
OCEANSIDE CA
92056-4506
US

IV. Provider business mailing address

4002 VISTA WAY
OCEANSIDE CA
92056-4506
US

V. Phone/Fax

Practice location:
  • Phone: 760-724-8411
  • Fax:
Mailing address:
  • Phone: 858-752-1395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86291607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: