Provider Demographics
NPI:1982375853
Name:MEDINA, ERICK SALVADOR (RD)
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:SALVADOR
Last Name:MEDINA
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 LA PLAYA WAY
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-4962
Mailing Address - Country:US
Mailing Address - Phone:661-474-9389
Mailing Address - Fax:
Practice Address - Street 1:1725 W 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-2316
Practice Address - Country:US
Practice Address - Phone:661-474-9389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86087913133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered