Basic Information
| Provider Information | |||||||||
| NPI: | 1003969221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UNGSON | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1020 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952013120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094686000 | ||||||||
| FaxNumber: | 2094687042 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W. HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | FRENCH CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952319989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094686000 | ||||||||
| FaxNumber: | 2094687042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | 570581 | CA | Y | Dietary & Nutritional Service Providers | Nutritionist |
ID Information
| ID | Type | State | Issuer | Description | 570581 | 01 | CA | REGISTERD DIETICIAN NUMBE | OTHER |