Healthcare Provider Details

I. General information

NPI: 1033404371
Provider Name (Legal Business Name): JAYMAR SANIATAN RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 NOTTOWAY TRL
MARIETTA GA
30066-7811
US

IV. Provider business mailing address

1251 NOTTOWAY TRL
MARIETTA GA
30066-7811
US

V. Phone/Fax

Practice location:
  • Phone: 818-481-4543
  • Fax:
Mailing address:
  • Phone: 818-481-4543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number896576
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number896576
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number896576
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number896576
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: