Healthcare Provider Details

I. General information

NPI: 1548172497
Provider Name (Legal Business Name): ZACHARY GEORGE STOW RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2606 AVIATION BLVD # 2606D
REDONDO BEACH CA
90278-1953
US

IV. Provider business mailing address

2606 AVIATION BLVD # 2606D
REDONDO BEACH CA
90278-1953
US

V. Phone/Fax

Practice location:
  • Phone: 417-830-2535
  • Fax: 417-830-2535
Mailing address:
  • Phone: 417-830-2535
  • Fax: 417-830-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86346994
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: