Healthcare Provider Details

I. General information

NPI: 1104121680
Provider Name (Legal Business Name): LEAH M TANNER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 SANTA ROSA ST SUITE A
SAN LUIS OBISPO CA
93405-1812
US

IV. Provider business mailing address

84 SANTA ROSA ST SUITE A
SAN LUIS OBISPO CA
93405-1812
US

V. Phone/Fax

Practice location:
  • Phone: 805-548-8585
  • Fax: 805-548-8589
Mailing address:
  • Phone: 805-548-8585
  • Fax: 805-548-8589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number919327
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: