Provider Demographics
NPI:1699926980
Name:THACKER, LORI (RD)
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:
Last Name:THACKER
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 1:2004 AVENUE OF THE TREES
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1104
Mailing Address - Country:US
Mailing Address - Phone:760-201-7665
Mailing Address - Fax:
Practice Address - Street 1:SAN DIEGO VA HEALTHCARE SYSTEM
Practice Address - Street 2:3350 LA JOLLA VILLAGE DRIVE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0001
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-05
Last Update Date:2008-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA915135133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered