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General NPI Number Information
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NPI Number | 1871065466
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Entity Type | Individual
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Provider Name | CRYSTAL CORCORAN RD
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Gender | Female
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Dates
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Enumeration Date | 12/20/2018
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Last Update Date | 12/20/2018
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Provider Practice Location Address
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Address Line | 295 POSADA LN STE C
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City | TEMPLETON
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State | CA
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Zip | 93465-4055
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Country | US
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Telephone | 805-434-1166
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Fax |
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Provider Business Mailing Address
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Address Line | 235 HEADWATERS RD
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City | TEMPLETON
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State | CA
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Zip | 93465-5131
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 1038419
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License Number State | CA
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