Provider Demographics
NPI:1245895556
Name:AVICENNA DIETETICS LLC
Entity type:Organization
Organization Name:AVICENNA DIETETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAGHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SEFIDBAKHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-259-0787
Mailing Address - Street 1:26730 TOWNE CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-2842
Mailing Address - Country:US
Mailing Address - Phone:949-259-0787
Mailing Address - Fax:
Practice Address - Street 1:26730 TOWNE CENTRE DR
Practice Address - Street 2:
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610-2842
Practice Address - Country:US
Practice Address - Phone:800-954-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-02
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty