Provider Demographics
NPI:1689280810
Name:GARCIA, SELENA ALICIA (DTR)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:ALICIA
Last Name:GARCIA
Suffix:
Gender:F
Credentials:DTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2066 MENDOCINO AVE APT 59
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-3653
Mailing Address - Country:US
Mailing Address - Phone:707-934-7482
Mailing Address - Fax:
Practice Address - Street 1:1287 FULTON RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4923
Practice Address - Country:US
Practice Address - Phone:877-717-0085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86291702136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered