Provider Demographics
NPI:1689020463
Name:FRAIRE, PAUL (RD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FRAIRE
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 1:7034 NEBRASKA ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-0822
Mailing Address - Country:US
Mailing Address - Phone:909-908-7951
Mailing Address - Fax:
Practice Address - Street 1:7034 NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-0822
Practice Address - Country:US
Practice Address - Phone:909-908-7951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA988451133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered