Provider Demographics
NPI:1275062192
Name:KWON, ELIOT (RDN)
Entity Type:Individual
Prefix:
First Name:ELIOT
Middle Name:
Last Name:KWON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4393 LARWIN AVE
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-4151
Mailing Address - Country:US
Mailing Address - Phone:310-490-5140
Mailing Address - Fax:
Practice Address - Street 1:4393 LARWIN AVE
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630-4151
Practice Address - Country:US
Practice Address - Phone:310-490-5140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86087413OtherCOMMISSION ON DIETETIC REGISTRATION