Provider Demographics
NPI:1407745250
Name:ODA, RYOKO GRACE
Entity type:Individual
Prefix:
First Name:RYOKO
Middle Name:GRACE
Last Name:ODA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5541 LAUREL CANYON BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-2131
Mailing Address - Country:US
Mailing Address - Phone:310-493-9539
Mailing Address - Fax:
Practice Address - Street 1:5541 LAUREL CANYON BLVD APT 3
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-2131
Practice Address - Country:US
Practice Address - Phone:310-493-9539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-28
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1063468133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered