MEDICARE: MAXWELL WALKER RD, LD

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	2013028579	MO

General Provider Information

NPI Number	:	1225461569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAXWELL WALKER RD, LD

Provider Business Mailing Address
First Line	:	1525 W HOMER ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-1280
Country	:	US
Telephone Number	:	888-785-7370
Fax Number	:

Provider Business Practice Location Address
First Line	:	818 SUGAR VALLEY CT
Second Line	:
City	:	SAINT PETERS
State	:	MO
Zip	:	63376-7474
Country	:	US
Telephone Number	:	719-694-4352
Fax Number	:

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

Provider Enumeration Date	:	08/09/2013
Last Update Date	:	08/09/2013

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