Healthcare Provider Details

I. General information

NPI: 1457138968
Provider Name (Legal Business Name): JOHN STANTON KUZIARA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/11/2023
Certification Date: 09/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 13TH ST
SANTA ROSA CA
95404-3961
US

IV. Provider business mailing address

1508 13TH ST
SANTA ROSA CA
95404-3961
US

V. Phone/Fax

Practice location:
  • Phone: 707-293-5398
  • Fax:
Mailing address:
  • Phone: 707-293-5398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86265494
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: