Provider Demographics
NPI:1801371489
Name:ACOSTA, JUANA (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:JUANA
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9539 HERMITAGE LN
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-6236
Mailing Address - Country:US
Mailing Address - Phone:562-458-7540
Mailing Address - Fax:
Practice Address - Street 1:3951 VAN BUREN BLVD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3620
Practice Address - Country:US
Practice Address - Phone:951-352-7178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1102447133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered