Provider Demographics
NPI:1023550829
Name:BACZKOWSKI, TERESA (RD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BACZKOWSKI
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 1:3303 FISH CANYON RD
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-1630
Mailing Address - Country:US
Mailing Address - Phone:323-260-5778
Mailing Address - Fax:323-881-8634
Practice Address - Street 1:1720 E CESAR E CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2414
Practice Address - Country:US
Practice Address - Phone:323-260-5778
Practice Address - Fax:323-881-8634
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR561270133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered