Healthcare Provider Details

I. General information

NPI: 1417536194
Provider Name (Legal Business Name): PATH WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 04/07/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5067 DURANGO CT
SAN JOSE CA
95118-2317
US

IV. Provider business mailing address

5067 DURANGO CT
SAN JOSE CA
95118-2317
US

V. Phone/Fax

Practice location:
  • Phone: 408-598-6064
  • Fax:
Mailing address:
  • Phone: 408-598-6064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: SRIDEVI SRINIVASAN
Title or Position: REGISTERED DIETITIAN NUTRITIONIST
Credential: RDN, CHWC
Phone: 408-598-6064