Basic Information
| Provider Information | |||||||||
| NPI: | 1205009222 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUPO | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 S SHAMROCK AVE APT D | ||||||||
| Address2: | |||||||||
| City: | MONROVIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910163000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263572700 | ||||||||
| FaxNumber: | 5627414413 | ||||||||
| Practice Location | |||||||||
| Address1: | 11525 BROOKSHIRE AVE STE 301 | ||||||||
| Address2: | ATTN MAGGIE NOLES | ||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902414982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5627414461 | ||||||||
| FaxNumber: | 5627414413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2008 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
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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 | 983732 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 983732 | 01 | CA | CDR | OTHER |