MEDICARE: SJ NUTRITION INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	870261	CA

General Provider Information

NPI Number	:	1376079434
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SJ NUTRITION INC.

Provider Business Mailing Address
First Line	:	20577 EAST OAK MEADOW LANE
Second Line	:
City	:	DIAMOND BAR
State	:	CA
Zip	:	91765
Country	:	US
Telephone Number	:	626-387-0196
Fax Number	:

Provider Business Practice Location Address
First Line	:	17134 COLIMA RD
Second Line	:	STE. E
City	:	HACIENDA HEIGHTS
State	:	CA
Zip	:	91745-6737
Country	:	US
Telephone Number	:	626-387-0196
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	SANDRA JORGENSEN
Credential	:	RDN
Telephone Number	:	626-340-9013

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	05/11/2017

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