Active NPI
Justin Matthew Waller, RDN
- Registered Dietitian
- San Luis Obispo, CA
National Provider Identifier
1699499335
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Dietitian
- License
- 86119710
- Practice address
- 500 E Foothill Blvd Apt 5
San Luis Obispo, CA 93405-1629 - Phone
- (916) 402-6914
- NPI assigned
- Sep 27, 2022
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Dietitian | 133V00000X | 86119710 | CA | Primary |
Addresses
Primary practice location
500 E Foothill Blvd Apt 5
San Luis Obispo, CA 93405-1629
Mailing address
500 E Foothill Blvd Apt 5
San Luis Obispo, CA 93405-1629
Phone (916) 402-6914
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 86119710 | CA | MD | Registered Dietitian |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Fay Nutrition | Dietitian, Registered | Past | Accepting new patients |
| Nourish, Inc. | Dietitian, Registered | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1664236800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1664236800000",
"number": "1699499335",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "500 E FOOTHILL BLVD APT 5",
"city": "SAN LUIS OBISPO",
"state": "CA",
"postal_code": "934051629",
"telephone_number": "916-402-6914"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "500 E FOOTHILL BLVD APT 5",
"city": "SAN LUIS OBISPO",
"state": "CA",
"postal_code": "934051629",
"telephone_number": "916-402-6914"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLER",
"first_name": "JUSTIN",
"middle_name": "MATTHEW",
"credential": "RDN",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2022-09-27",
"last_updated": "2022-09-27",
"certification_date": "2022-09-27",
"status": "A"
},
"taxonomies": [
{
"code": "133V00000X",
"taxonomy_group": "",
"desc": "Dietitian, Registered",
"state": "CA",
"license": "86119710",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Luis Obispo, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 27, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.