MEDICARE: RENEE HENICO RD CD

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	133V00000X	Registered Dietitian	37002017A	IN

General Provider Information

NPI Number	:	1043522048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENEE HENICO RD CD

Provider Business Mailing Address
First Line	:	6145 NORTH CR 940 WEST
Second Line	:
City	:	MIDDLETOWN
State	:	IN
Zip	:	47356-9530
Country	:	US
Telephone Number	:	765-620-8400
Fax Number	:	765-779-4010

Provider Business Practice Location Address
First Line	:	6145 NORTH CR 940 WEST
Second Line	:
City	:	MIDDLETOWN
State	:	IN
Zip	:	47356-9530
Country	:	US
Telephone Number	:	765-620-8400
Fax Number	:	765-779-4010

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

Provider Enumeration Date	:	07/07/2010
Last Update Date	:	07/07/2010

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Directions to “ RENEE HENICO RD CD” Practice Location

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