MEDICARE: JAN WAGNER RDLD

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	4781	OH

General Provider Information

NPI Number	:	1154738078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAN WAGNER RDLD

Provider Business Mailing Address
First Line	:	1521 ST.CLAIR AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45231
Country	:	US
Telephone Number	:	513-931-0452
Fax Number	:

Provider Business Practice Location Address
First Line	:	4851 WUNNENBERG WAY
Second Line	:
City	:	WEST CHESTER
State	:	OH
Zip	:	45069-4855
Country	:	US
Telephone Number	:	513-874-8800
Fax Number	:

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

Provider Enumeration Date	:	07/14/2014
Last Update Date	:	07/14/2014

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