1962943217 NPI number — SARAH DOROTHY MINKOW MS, RDN

Table of content: SARAH DOROTHY MINKOW MS, RDN (NPI 1962943217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962943217 NPI number — SARAH DOROTHY MINKOW MS, RDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MINKOW
Provider First Name:
SARAH
Provider Middle Name:
DOROTHY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, RDN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALATKA
Provider Other First Name:
SARAH
Provider Other Middle Name:
DOROTHY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962943217
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1443 MAIN STREET, STE 130B
Provider Second Line Business Mailing Address:
NAPA
Provider Business Mailing Address City Name:
CA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94559-1939
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-200-1178
Provider Business Mailing Address Fax Number:
707-847-8698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 9TH PL
Provider Second Line Business Practice Location Address:
B
Provider Business Practice Location Address City Name:
MANHATTAN BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90266-5661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-464-7895
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  86036712 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 86036712 . This is a "RD NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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