Healthcare Provider Details

I. General information

NPI: 1306452321
Provider Name (Legal Business Name): ERIN BROGDON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 10/08/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 S STRATFORD AVE STE B
SANTA MARIA CA
93454-5908
US

IV. Provider business mailing address

1400 E CHURCH ST MEDICAL STAFF OFFICE
SANTA MARIA CA
93454
US

V. Phone/Fax

Practice location:
  • Phone: 805-332-8446
  • Fax: 805-332-8173
Mailing address:
  • Phone: 805-739-3114
  • Fax: 805-739-3502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number86115833
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86115833
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: