Healthcare Provider Details

I. General information

NPI: 1316109028
Provider Name (Legal Business Name): EILEEN M OLMSTEAD RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 RIDGEWOOD DR
RESCUE CA
95672-9472
US

IV. Provider business mailing address

1307 RIDGEWOOD DR
RESCUE CA
95672-9472
US

V. Phone/Fax

Practice location:
  • Phone: 530-672-1514
  • Fax: 530-672-1514
Mailing address:
  • Phone: 530-672-1514
  • Fax: 530-672-1514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number949057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: