Provider Demographics
NPI:1124280557
Name:SODERQUIST, RENEE M (RD)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:M
Last Name:SODERQUIST
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E VALENCIA MESA DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3813
Mailing Address - Country:US
Mailing Address - Phone:714-446-5640
Mailing Address - Fax:714-446-5625
Practice Address - Street 1:100 E VALENCIA MESA DR
Practice Address - Street 2:SUITE 105
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3813
Practice Address - Country:US
Practice Address - Phone:714-446-5640
Practice Address - Fax:714-446-5625
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR711364133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR711364OtherRD LIC NUMBER
CADO626ZMedicare PIN