Organization
LEPORT
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELLEN ROHAN (PRACTICE MANAGER)
(714) 861-4666
Entity
Organization
Contact information
Practice address
18111 BROOKHURST ST, SUITE 5600, FOUNTAIN VALLEY, CA 92708-6728
(714) 861-4666
(714) 861-4674
Mailing address
18111 BROOKHURST ST, SUITE 5600, FOUNTAIN VALLEY, CA 92708-6728
(714) 861-4666
(714) 861-4674
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
963173
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G471930
—
CA
Enumeration date
07/31/2015
Last updated
07/31/2015
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