Healthcare Provider Details

I. General information

NPI: 1699133090
Provider Name (Legal Business Name): MICHELE CROSMER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 E 9TH ST STE 320
UPLAND CA
91786-6023
US

IV. Provider business mailing address

8431 HAWTHORNE ST
ALTA LOMA CA
91701-4544
US

V. Phone/Fax

Practice location:
  • Phone: 909-912-4060
  • Fax: 888-974-4248
Mailing address:
  • Phone: 909-912-4060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86014375
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: