Provider Demographics
NPI:1043957996
Name:PRIMMER, JOHNATHON SCOTT (RDN)
Entity type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:SCOTT
Last Name:PRIMMER
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11400 215TH ST APT 12
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90715-2071
Mailing Address - Country:US
Mailing Address - Phone:719-648-2821
Mailing Address - Fax:
Practice Address - Street 1:10418 VALLEY BLVD STE A
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-3600
Practice Address - Country:US
Practice Address - Phone:626-258-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86294236133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86294236OtherCOMMISSION OF DIETETICS REGISTERED