Provider Demographics
NPI:1982036794
Name:KACZOR, KATHERINE ELIZABETH (RD)
Entity Type:Individual
Prefix:MISS
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:KACZOR
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 ARGONNE AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-3231
Mailing Address - Country:US
Mailing Address - Phone:562-434-6007
Mailing Address - Fax:
Practice Address - Street 1:191 ARGONNE AVE
Practice Address - Street 2:STE 3
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-3231
Practice Address - Country:US
Practice Address - Phone:562-434-6007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1066193133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered