Healthcare Provider Details

I. General information

NPI: 1174619076
Provider Name (Legal Business Name): ALMA Y GEPFORD RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16716 BEAR VALLEY RD
VICTORVILLE CA
92395-5797
US

IV. Provider business mailing address

16850 BEAR VALLEY RD
VICTORVILLE CA
92395-5794
US

V. Phone/Fax

Practice location:
  • Phone: 760-241-8000
  • Fax:
Mailing address:
  • Phone: 760-241-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberR576344
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: