MEDICARE: KELLIE GLASER RDN

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	01043807	CA

General Provider Information

NPI Number	:	1821545054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE GLASER RDN

Provider Business Mailing Address
First Line	:	1759 DUNE POINT WAY
Second Line	:
City	:	DISCOVERY BAY
State	:	CA
Zip	:	94505-9356
Country	:	US
Telephone Number	:	909-831-4034
Fax Number	:

Provider Business Practice Location Address
First Line	:	1759 DUNE POINT WAY
Second Line	:
City	:	DISCOVERY BAY
State	:	CA
Zip	:	94505-9356
Country	:	US
Telephone Number	:	909-831-4034
Fax Number	:

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

Provider Enumeration Date	:	09/06/2016
Last Update Date	:	09/06/2016

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