Healthcare Provider Details

I. General information

NPI: 1740556075
Provider Name (Legal Business Name): LINDSAY KOH R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 02/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 DONNA WAY
SAN JACINTO CA
92583-5517
US

IV. Provider business mailing address

24588 UNIVERSITY AVE SUITE B
LOMA LINDA CA
92354-2774
US

V. Phone/Fax

Practice location:
  • Phone: 951-654-0803
  • Fax:
Mailing address:
  • Phone: 817-505-7743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86002257
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: