Healthcare Provider Details

I. General information

NPI: 1093725434
Provider Name (Legal Business Name): YESENIA CIHUACOATL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: YESENIA GARZA

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 N CALIFORNIA ST SUITE 2G
STOCKTON CA
95204-6117
US

IV. Provider business mailing address

1617 N. CALIFORNIA STREET SUITE 2G
STOCKTON CA
95204-6019
US

V. Phone/Fax

Practice location:
  • Phone: 209-461-5268
  • Fax: 209-461-5395
Mailing address:
  • Phone: 209-461-5268
  • Fax: 209-461-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number956706
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: