Provider Demographics
NPI:1306452321
Name:BROGDON, ERIN (RD)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:BROGDON
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 1:1400 E CHURCH ST
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454
Mailing Address - Country:US
Mailing Address - Phone:805-739-3114
Mailing Address - Fax:805-739-3502
Practice Address - Street 1:316 S STRATFORD AVE STE B
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5908
Practice Address - Country:US
Practice Address - Phone:805-332-8446
Practice Address - Fax:805-332-8173
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86115833136A00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, RegisteredGroup - Multi-Specialty