Basic Information
| Provider Information | |||||||||
| NPI: | 1063977312 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKENZIE | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | GAIL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6382 N BRENDA LN | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924074039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099652880 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18300 CA-18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602422311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2019 | ||||||||
| LastUpdateDate: | 01/31/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86075778 | CA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133VN1004X | 86075778 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric |
ID Information
| ID | Type | State | Issuer | Description | 86075778 | 01 | CA | ACADEMY OF NUTRITION AND DIETETICS | OTHER |