Healthcare Provider Details

I. General information

NPI: 1760738413
Provider Name (Legal Business Name): NUTRITION BASED INTEGRATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

758 UNIVERSITY AVE
SACRAMENTO CA
95825-6703
US

IV. Provider business mailing address

9115 YELLOW FLOWER PL
FAIR OAKS CA
95628-6563
US

V. Phone/Fax

Practice location:
  • Phone: 916-564-3300
  • Fax: 916-927-1831
Mailing address:
  • Phone: 916-564-3300
  • Fax: 916-927-1831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A10508
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number20A10508
License Number StateCA

VIII. Authorized Official

Name: WAYNE DANIEL
Title or Position: OWNER
Credential: D.O.
Phone: 916-564-3300