Healthcare Provider Details

I. General information

NPI: 1568512804
Provider Name (Legal Business Name): PRABHA TADIBOYANA DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 168TH AVENUE KAISER POST ACUTE CARE CENTER
SAN LEANDRO CA
94578
US

IV. Provider business mailing address

20800 HOMESTEAD RD APT # 17 G
CUPERTINO CA
95014-0458
US

V. Phone/Fax

Practice location:
  • Phone: 510-481-6319
  • Fax:
Mailing address:
  • Phone: 408-517-0992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number943807
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: