MEDICARE: CALIFORNIA CLINICAL NUTRITION SERVICES LLC

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

General Provider Information

NPI Number	:	1871431312
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALIFORNIA CLINICAL NUTRITION SERVICES LLC

Provider Business Mailing Address
First Line	:	19207 AMBER VALLEY DR
Second Line	:
City	:	WALNUT
State	:	CA
Zip	:	91789-4505
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1309 W MISSION BLVD UNIT 50
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91762-6845
Country	:	US
Telephone Number	:	951-691-0933
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NICOLE JIN
Credential	:
Telephone Number	:	951-691-0933

Provider Enumeration Date	:	03/24/2026
Last Update Date	:	03/24/2026

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