Provider Demographics
NPI:1942500392
Name:NUTRITION STUDIO & DIABETES CARE CENTER INC
Entity Type:Organization
Organization Name:NUTRITION STUDIO & DIABETES CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIABETES EDUCATOR AND PROGRAM DIREC
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:WARMERDAM
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:209-832-3432
Mailing Address - Street 1:471 W EATON AVE
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3420
Mailing Address - Country:US
Mailing Address - Phone:209-832-3432
Mailing Address - Fax:209-839-6742
Practice Address - Street 1:471 W EATON AVE
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3420
Practice Address - Country:US
Practice Address - Phone:209-832-3432
Practice Address - Fax:209-839-6742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR703135133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP51846Medicare UPIN