Provider Demographics
NPI:1043265622
Name:LICCIARDO, BETTY (RD)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:LICCIARDO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:BETTY
Other - Middle Name:
Other - Last Name:SLESINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:840 TOWNE CENTER DRIVE
Mailing Address - Street 2:CHAPARRAL MEDICAL GROUP INC
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1573
Practice Address - Street 1:1904 N ORANGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3008
Practice Address - Country:US
Practice Address - Phone:909-469-1823
Practice Address - Fax:909-469-1827
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
718614133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WNT718614AMedicare ID - Type Unspecified
WNT718614BMedicare ID - Type Unspecified