Provider Demographics
NPI:1699718288
Name:MUNDELL, BETH (RD)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:MUNDELL
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 1:24642 MOSQUERO LN
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-4913
Mailing Address - Country:US
Mailing Address - Phone:949-764-6240
Mailing Address - Fax:949-642-7703
Practice Address - Street 1:1901 NEWPORT BLVD
Practice Address - Street 2:SUITE 175
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2278
Practice Address - Country:US
Practice Address - Phone:949-764-6240
Practice Address - Fax:949-642-7703
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
717253133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWNT717253AOtherPPIN