Provider Demographics
NPI:1063269587
Name:MITCHELL, THEODORE R IV (RDN)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:R
Last Name:MITCHELL
Suffix:IV
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 W 51ST PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-2341
Mailing Address - Country:US
Mailing Address - Phone:424-646-0619
Mailing Address - Fax:
Practice Address - Street 1:1727 W 51ST PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90062-2341
Practice Address - Country:US
Practice Address - Phone:424-646-0619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric