Healthcare Provider Details

I. General information

NPI: 1689280810
Provider Name (Legal Business Name): SELENA ALICIA GARCIA DTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1287 FULTON RD
SANTA ROSA CA
95401-4923
US

IV. Provider business mailing address

2066 MENDOCINO AVE APT 59
SANTA ROSA CA
95401-3653
US

V. Phone/Fax

Practice location:
  • Phone: 877-717-0085
  • Fax:
Mailing address:
  • Phone: 707-934-7482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number86291702
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: