Healthcare Provider Details

I. General information

NPI: 1699926980
Provider Name (Legal Business Name): LORI THACKER R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2008
Last Update Date: 10/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SAN DIEGO VA HEALTHCARE SYSTEM 3350 LA JOLLA VILLAGE DRIVE
SAN DIEGO CA
92161-0001
US

IV. Provider business mailing address

2004 AVENUE OF THE TREES
CARLSBAD CA
92008-1104
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-8585
  • Fax:
Mailing address:
  • Phone: 760-201-7665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number915135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: