MEDICARE: AMELIA TAVARES

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
2	174N00000X	Lactation Consultant (Non-RN)

General Provider Information

NPI Number	:	1366061913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMELIA TAVARES

Provider Business Mailing Address
First Line	:	1188 GALESMORE CT
Second Line	:
City	:	WESTLAKE VILLAGE
State	:	CA
Zip	:	91361-1647
Country	:	US
Telephone Number	:	209-402-1402
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 VALLEY VIEW DR STE 104
Second Line	:
City	:	MONTANA CITY
State	:	MT
Zip	:	59634-9203
Country	:	US
Telephone Number	:	406-459-6092
Fax Number	:

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

Provider Enumeration Date	:	04/14/2020
Last Update Date	:	04/14/2020

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Directions to “ AMELIA TAVARES ” Practice Location

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