MEDICARE: ATHEA GUILFOYLE 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	007445	NY
2	133V00000X	Registered Dietitian	1064077

General Provider Information

NPI Number	:	1659775450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ATHEA GUILFOYLE RD

Provider Business Mailing Address
First Line	:	3350 LA JOLLA VILLAGE DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92161-0002
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3350 LA JOLLA VILLAGE DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92161-3309
Country	:	US
Telephone Number	:	518-338-7537
Fax Number	:

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

Provider Enumeration Date	:	10/22/2014
Last Update Date	:	01/26/2022

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Directions to “ ATHEA GUILFOYLE RD” Practice Location

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