Provider Demographics
NPI:1326405804
Name:RAIMO, JOHN (RDN)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RAIMO
Suffix:
Gender:M
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:PO BOX 3315
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:CA
Mailing Address - Zip Code:95971-3315
Mailing Address - Country:US
Mailing Address - Phone:775-250-7579
Mailing Address - Fax:530-258-3981
Practice Address - Street 1:130 BRENTWOOD DR.
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:CA
Practice Address - Zip Code:96020
Practice Address - Country:US
Practice Address - Phone:530-258-3981
Practice Address - Fax:530-258-4248
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
CA810702133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered