MEDICARE: NICOLE GILLES RD, CDE, CSR

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	1034797	CA

General Provider Information

NPI Number	:	1952657785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE GILLES RD, CDE, CSR

Provider Business Mailing Address
First Line	:	12523 LIMONITE AVE # 440-163
Second Line	:
City	:	MIRA LOMA
State	:	CA
Zip	:	91752-3665
Country	:	US
Telephone Number	:	951-444-5588
Fax Number	:	877-991-8768

Provider Business Practice Location Address
First Line	:	12523 LIMONITE AVE
Second Line	:	#440-163
City	:	MIRA LOMA
State	:	CA
Zip	:	91752-3665
Country	:	US
Telephone Number	:	951-444-5588
Fax Number	:	877-991-8768

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

Provider Enumeration Date	:	07/30/2012
Last Update Date	:	12/23/2014

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