Healthcare Provider Details

I. General information

NPI: 1073397287
Provider Name (Legal Business Name): YIMENG MA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

561 WESTGATE ST
PASADENA CA
91103-2824
US

IV. Provider business mailing address

561 WESTGATE ST
PASADENA CA
91103-2824
US

V. Phone/Fax

Practice location:
  • Phone: 626-679-3530
  • Fax:
Mailing address:
  • Phone: 626-679-3530
  • 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 Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: YIMENG MA
Title or Position: OWNER
Credential:
Phone: 626-679-3530