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NPI Code Detail

MEDICARE: COLEEN LISCANO MS, RD, CNSD. CLE

MEDICARE: COLEEN LISCANO MS, RD, CNSD. CLE
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
1133VN1004XPediatric Nutrition Registered Dietitian877908CA

General Provider Information

NPI Number : 1972831139
Entity Type Code : Individual
Provider Name (Legal Business Name) : COLEEN LISCANO MS, RD, CNSD. CLE
Provider Business Mailing Address
First Line : 2159 E BADILLO ST
Second Line :
City : COVINA
State : CA
Zip : 91724-2340
Country : US
Telephone Number : 323-361-4789
Fax Number :
Provider Business Practice Location Address
First Line : 2159 E BADILLO ST
Second Line :
City : COVINA
State : CA
Zip : 91724-2340
Country : US
Telephone Number : 714-931-7157
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/30/2009
Last Update Date : 11/30/2009

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