Provider Demographics
NPI:1053666230
Name:VICENCIO, RONWALD (RD)
Entity Type:Individual
Prefix:
First Name:RONWALD
Middle Name:
Last Name:VICENCIO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 LINCOLN AVE APT B
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-3330
Mailing Address - Country:US
Mailing Address - Phone:510-610-8307
Mailing Address - Fax:
Practice Address - Street 1:753 LINCOLN AVE APT B
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-3330
Practice Address - Country:US
Practice Address - Phone:510-610-8307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1107190133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered