Provider Demographics
NPI:1942448139
Name:VIVAS, MICHELE RENE (MS, RD)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:RENE
Last Name:VIVAS
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 RUBIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602
Mailing Address - Country:US
Mailing Address - Phone:510-595-9474
Mailing Address - Fax:510-595-9470
Practice Address - Street 1:5665 COLLEGE AVENUE
Practice Address - Street 2:SUITE 220 B
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602
Practice Address - Country:US
Practice Address - Phone:510-595-9474
Practice Address - Fax:510-595-9470
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL717019133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered