Healthcare Provider Details

I. General information

NPI: 1922218221
Provider Name (Legal Business Name): HOLLY MAY SCHROEDER RD, CNSD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 HEALTH CENTER DR
SAN DIEGO CA
92123-2700
US

IV. Provider business mailing address

4533 IDAHO ST # 1
SAN DIEGO CA
92116-3154
US

V. Phone/Fax

Practice location:
  • Phone: 858-939-4269
  • Fax: 858-939-4269
Mailing address:
  • Phone: 858-939-4269
  • Fax: 858-939-4948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number715435
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: