Provider Demographics
NPI:1003538323
Name:REISINGER, LILY VALENTINE (RD)
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:VALENTINE
Last Name:REISINGER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 HARVARD ST APT D
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4788
Mailing Address - Country:US
Mailing Address - Phone:314-578-8668
Mailing Address - Fax:
Practice Address - Street 1:21515 HAWTHORNE BLVD STE 370
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-6556
Practice Address - Country:US
Practice Address - Phone:424-341-5407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86290554133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered