Provider Demographics
NPI:1447783048
Name:FRAIRE, MARILOU (RD)
Entity Type:Individual
Prefix:MRS
First Name:MARILOU
Middle Name:
Last Name:FRAIRE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17296 SLOVER AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-7585
Mailing Address - Country:US
Mailing Address - Phone:909-609-3000
Mailing Address - Fax:
Practice Address - Street 1:17296 SLOVER AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-7585
Practice Address - Country:US
Practice Address - Phone:909-609-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA987777133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered