Healthcare Provider Details

I. General information

NPI: 1265803076
Provider Name (Legal Business Name): NUTRITION CARE PLUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26572 ROYALE DR
SAN JUAN CAPISTRANO CA
92675-1412
US

IV. Provider business mailing address

26572 ROYALE DR
SAN JUAN CAPISTRANO CA
92675-1412
US

V. Phone/Fax

Practice location:
  • Phone: 949-429-3320
  • Fax: 949-429-3302
Mailing address:
  • Phone: 949-429-3320
  • Fax: 949-429-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number932113
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code335G00000X
TaxonomyMedical Foods Supplier
License Number932113
License Number StateCA

VIII. Authorized Official

Name: LEYLA KAVUSI DAVIJANI
Title or Position: PRESIDENT
Credential: RD
Phone: 949-606-3573