Healthcare Provider Details

I. General information

NPI: 1588347462
Provider Name (Legal Business Name): MNT SCIENTIFIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3079 HARRISON AVE
SOUTH LAKE TAHOE CA
96150
US

IV. Provider business mailing address

671 RIVER RANCH ROAD
MARKLEEVILLE CA
96120
US

V. Phone/Fax

Practice location:
  • Phone: 909-653-3471
  • Fax: 949-260-0134
Mailing address:
  • Phone: 909-653-3471
  • Fax: 949-269-0134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: DR. PATRICK LACKMANN TRAYNOR
Title or Position: OWNER
Credential: RD
Phone: 909-653-3471