Healthcare Provider Details

I. General information

NPI: 1285241844
Provider Name (Legal Business Name): PAOLINA MULLENEIX RD,LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 DAGGETT AVE
KLAMATH FALLS OR
97601-1106
US

IV. Provider business mailing address

4419 BRISTOL AVE
KLAMATH FALLS OR
97603-8023
US

V. Phone/Fax

Practice location:
  • Phone: 541-882-6311
  • Fax:
Mailing address:
  • Phone: 760-600-6246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10209683
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: