Provider Demographics
NPI:1770101537
Name:GOODRICH, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 9TH ST APT 407
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2756
Mailing Address - Country:US
Mailing Address - Phone:305-527-5846
Mailing Address - Fax:
Practice Address - Street 1:1639 11TH ST # B-230
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3727
Practice Address - Country:US
Practice Address - Phone:305-527-5846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered