Provider Demographics
NPI:1659825008
Name:MUNIZICH, EDMOND JOSEPH (RD)
Entity Type:Individual
Prefix:MR
First Name:EDMOND
Middle Name:JOSEPH
Last Name:MUNIZICH
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 W VALERIO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-4952
Mailing Address - Country:US
Mailing Address - Phone:805-696-1128
Mailing Address - Fax:
Practice Address - Street 1:315 CAMINO DEL REMEDIO
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93110-1332
Practice Address - Country:US
Practice Address - Phone:805-681-5275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-14
Last Update Date:2016-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA859472133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered