Provider Demographics
NPI:1548618952
Name:KOO, REBECCA KIN (RD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:KIN
Last Name:KOO
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 1:15945 HORNELL ST
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90603-2838
Mailing Address - Country:US
Mailing Address - Phone:949-351-2695
Mailing Address - Fax:
Practice Address - Street 1:2444 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2306
Practice Address - Country:US
Practice Address - Phone:323-201-4130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86028862133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered