Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 27733 DC | CA |
NPI | 1275892283 |
---|---|
Provider Name | Dr. Scot Alexander Collie |
First Address | Santa Ana, CA 92704-6916 |
Second Address | Irvine, CA 92603-1012 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2012 |
Last Update Date | 10/05/2012 |