Healthcare Provider Details

I. General information

NPI: 1750814422
Provider Name (Legal Business Name): THIA LE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2017
Last Update Date: 04/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12401 WASHINGTON BLVD
WHITTIER CA
90602-1006
US

IV. Provider business mailing address

9015 HERSHEY ST
ROSEMEAD CA
91770-2828
US

V. Phone/Fax

Practice location:
  • Phone: 562-698-0811
  • Fax:
Mailing address:
  • Phone: 323-547-6398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number891999
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number891999
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number891999
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: