MEDICARE: THE DYSFUNCTIONAL DIETITIAN

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

General Provider Information

NPI Number	:	1225676414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE DYSFUNCTIONAL DIETITIAN

Provider Business Mailing Address
First Line	:	2229 MARSH VIEW DR UNIT 203
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33544-4718
Country	:	US
Telephone Number	:	252-267-6580
Fax Number	:

Provider Business Practice Location Address
First Line	:	2229 MARSH VIEW DR UNIT 203
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33544-4718
Country	:	US
Telephone Number	:	252-267-6580
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SYNOVIA J SIMONS
Credential	:	RDN
Telephone Number	:	252-267-6580

Provider Enumeration Date	:	12/18/2019
Last Update Date	:	01/16/2020

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Directions to “THE DYSFUNCTIONAL DIETITIAN ” Practice Location

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