Healthcare Provider Details

I. General information

NPI: 1831663863
Provider Name (Legal Business Name): CORINNE KANTOR DTR, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2019
Last Update Date: 01/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 PASEO PRIMERO
RANCHO SANTA MARGARITA CA
92688-3361
US

IV. Provider business mailing address

27758 SANTA MARGARITA PKWY STE 410
MISSION VIEJO CA
92691-6709
US

V. Phone/Fax

Practice location:
  • Phone: 949-888-1793
  • Fax:
Mailing address:
  • Phone: 949-888-1793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: