MEDICARE: MRS. LISA M. BRADT RD, CSR, CDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1005X	Renal Nutrition Registered Dietitian	005925-1	NY

General Provider Information

NPI Number	:	1023282738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA M. BRADT RD, CSR, CDN

Provider Business Mailing Address
First Line	:	4490 SENECA ST
Second Line	:
City	:	WEST SENECA
State	:	NY
Zip	:	14224-3139
Country	:	US
Telephone Number	:	716-677-0102
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 DELAWARE AVE
Second Line	:	SUITE 100
City	:	BUFFALO
State	:	NY
Zip	:	14202-1807
Country	:	US
Telephone Number	:	716-903-3730
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2008
Last Update Date	:	05/13/2008

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