MEDICARE: KELSEA JOHANNA CREGUT RD

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	1036705	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CB280422	OTHER	CA	MEDICARE

General Provider Information

NPI Number	:	1376906594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEA JOHANNA CREGUT RD

Provider Business Mailing Address
First Line	:	5709 CHERRY RIDGE DR
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93012-5515
Country	:	US
Telephone Number	:	805-444-5919
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 MOBIL AVE STE D27
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93010-6338
Country	:	US
Telephone Number	:	805-444-5919
Fax Number	:	805-830-1735

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2016
Last Update Date	:	06/11/2019

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