Basic Information
| Provider Information | |||||||||
| NPI: | 1154752400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESROCHES | ||||||||
| FirstName: | SOPHIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 N BRENT ST | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930032809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056525066 | ||||||||
| FaxNumber: | 8056411706 | ||||||||
| Practice Location | |||||||||
| Address1: | 147 N BRENT ST | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930032809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056525066 | ||||||||
| FaxNumber: | 8056411706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2013 | ||||||||
| LastUpdateDate: | 12/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1011980 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1011980 | 01 | CA | CERTIFICATE | OTHER |