Provider Demographics
NPI:1346382546
Name:CORDOVA, BETH ELISE (RD, CLE)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ELISE
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:RD, CLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 CHAMPION WAY
Mailing Address - Street 2:266
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1243
Mailing Address - Country:US
Mailing Address - Phone:714-917-9893
Mailing Address - Fax:
Practice Address - Street 1:2955 CHAMPION WAY
Practice Address - Street 2:266
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-1243
Practice Address - Country:US
Practice Address - Phone:714-917-9893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA865478133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered