Provider Demographics
NPI:1760633028
Name:EBELING, MYRA KURTZ (RD)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:KURTZ
Last Name:EBELING
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4004 BEYER BLVD
Mailing Address - Street 2:SAN YSIDRO
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-2007
Mailing Address - Country:US
Mailing Address - Phone:619-662-4100
Mailing Address - Fax:619-427-0134
Practice Address - Street 1:865 3RD AVE
Practice Address - Street 2:CHULA VISTA
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1300
Practice Address - Country:US
Practice Address - Phone:619-662-4100
Practice Address - Fax:619-427-0134
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA912662133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered