Provider Demographics
NPI:1841972007
Name:GLUCOSAMIGOS PC
Entity type:Organization
Organization Name:GLUCOSAMIGOS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:HENG
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:909-214-6301
Mailing Address - Street 1:1254 S WATERMAN AVE STE 28
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2857
Mailing Address - Country:US
Mailing Address - Phone:909-763-2551
Mailing Address - Fax:866-475-0054
Practice Address - Street 1:1254 S WATERMAN AVE STE 28
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2857
Practice Address - Country:US
Practice Address - Phone:909-763-2551
Practice Address - Fax:866-475-0054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-07
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty