Healthcare Provider Details

I. General information

NPI: 1720745086
Provider Name (Legal Business Name): EMILY BEJTLICH RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2021
Last Update Date: 11/22/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 WILSHIRE BLVD STE 505
SANTA MONICA CA
90403-5640
US

IV. Provider business mailing address

8391 BEVERLY BLVD UNIT 112
LOS ANGELES CA
90048-2633
US

V. Phone/Fax

Practice location:
  • Phone: 774-487-8322
  • Fax:
Mailing address:
  • Phone: 774-487-8322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86151189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: