Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 015972 | CA |
NPI | 1003909409 |
---|---|
Provider Name | Andrew J. Keith |
First Address | West Covina, CA 91792-1537 |
Second Address | West Covina, CA 91792-1537 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T18200 | (02) | CA |