Basic Information
| Provider Information | |||||||||
| NPI: | 1871076893 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PYWTORAK | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 S BLOSSER RD | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934587310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053618030 | ||||||||
| FaxNumber: | 8053618097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 LAS TABLAS RD | ||||||||
| Address2: | |||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934659758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055426700 | ||||||||
| FaxNumber: | 8055426791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2018 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 847899 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.