Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 15881 | CA |
NPI | 1376850776 |
---|---|
Provider Name | Greg Cantu |
First Address | Del Mar, CA 92014-3860 |
Second Address | Del Mar, CA 92014-3860 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2010 |
Last Update Date | 07/09/2010 |