MEDICARE: KELLY PYWTORAK 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	847899	CA

General Provider Information

NPI Number	:	1871076893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY PYWTORAK RDN

Provider Business Mailing Address
First Line	:	2050 S BLOSSER RD
Second Line	:
City	:	SANTA MARIA
State	:	CA
Zip	:	93458-7310
Country	:	US
Telephone Number	:	805-361-8030
Fax Number	:	805-361-8097

Provider Business Practice Location Address
First Line	:	1330 LAS TABLAS RD
Second Line	:
City	:	TEMPLETON
State	:	CA
Zip	:	93465-9758
Country	:	US
Telephone Number	:	805-542-6700
Fax Number	:	805-542-6791

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

Provider Enumeration Date	:	09/14/2018
Last Update Date	:	08/19/2021

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