Provider Demographics
NPI:1871041749
Name:GOETERS, GWEN (RDN)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:GOETERS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7022 RUGBY AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4724
Mailing Address - Country:US
Mailing Address - Phone:323-757-7244
Mailing Address - Fax:323-905-7827
Practice Address - Street 1:7022 RUGBY AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4724
Practice Address - Country:US
Practice Address - Phone:323-757-7244
Practice Address - Fax:323-905-7827
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA720092133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered