Provider Demographics
NPI:1689029878
Name:WOODWARD, ANDREW (MS, RD, CSO)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:WOODWARD
Suffix:
Gender:M
Credentials:MS, RD, CSO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8455 LODGEPOLE LN
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-7105
Mailing Address - Country:US
Mailing Address - Phone:951-203-3053
Mailing Address - Fax:
Practice Address - Street 1:8455 LODGEPOLE LN
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-7105
Practice Address - Country:US
Practice Address - Phone:951-203-3053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA707682133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic