Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 4185 | CA |
NPI | 1306967047 |
---|---|
Provider Name | Michael Simeon Shpak |
First Address | Walnut Creek, CA 94598-4445 |
Second Address | Pleasant Hill, CA 94523-4602 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2007 |
Last Update Date | 08/07/2007 |