Healthcare Provider Details

I. General information

NPI: 1164048757
Provider Name (Legal Business Name): SOCAL NUTRITIONISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W 30TH ST
SAN PEDRO CA
90731
US

IV. Provider business mailing address

720 W 30TH ST
SAN PEDRO CA
90731-6616
US

V. Phone/Fax

Practice location:
  • Phone: 310-395-7973
  • Fax:
Mailing address:
  • Phone: 424-280-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: SAIRA G TORRES
Title or Position: CEO
Credential: RDN
Phone: 424-280-6110