Healthcare Provider Details

I. General information

NPI: 1649693672
Provider Name (Legal Business Name): LAUREN FOLEY WENDEROTH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SMITH RANCH RD
SAN RAFAEL CA
94903-1939
US

IV. Provider business mailing address

21 TAMAL VISTA BLVD STE 208
CORTE MADERA CA
94925-1130
US

V. Phone/Fax

Practice location:
  • Phone: 415-491-3000
  • Fax:
Mailing address:
  • Phone: 888-945-6887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86009594
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: