Provider Demographics
NPI:1386961456
Name:MACASO, EARL JUSTIN (RD)
Entity type:Individual
Prefix:MR
First Name:EARL JUSTIN
Middle Name:
Last Name:MACASO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 VIA PALMA
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-4751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 W COVINA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3245
Practice Address - Country:US
Practice Address - Phone:909-581-4324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1014480133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered