Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | DC 25433 | CA |
NPI | 1598980344 |
---|---|
Provider Name | Dr. John Richard Ennen |
First Address | Tustin, CA 92780-3745 |
Second Address | Tustin, CA 92780-3745 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/04/2007 |
Last Update Date | 08/07/2007 |