Healthcare Provider Details

I. General information

NPI: 1801286240
Provider Name (Legal Business Name): SOBHA MALLA RD, CSR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 CENTER GROVE RD
RANDOLPH NJ
07869-4453
US

IV. Provider business mailing address

121 CENTER GROVE RD
RANDOLPH NJ
07869-4453
US

V. Phone/Fax

Practice location:
  • Phone: 315-834-2382
  • Fax:
Mailing address:
  • Phone: 510-792-2652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number931194
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: