Provider Demographics
NPI:1376079434
Name:SJ NUTRITION INC.
Entity Type:Organization
Organization Name:SJ NUTRITION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:626-340-9013
Mailing Address - Street 1:20577 EAST OAK MEADOW LANE
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765
Mailing Address - Country:US
Mailing Address - Phone:626-387-0196
Mailing Address - Fax:
Practice Address - Street 1:17134 COLIMA RD
Practice Address - Street 2:STE. E
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-6737
Practice Address - Country:US
Practice Address - Phone:626-387-0196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA870261133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANPI 1366646994Medicare PIN