MEDICARE: ELIZABETH BARNETT BOEBEL RD

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	DT82978	TX

General Provider Information

NPI Number	:	1497170922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH BARNETT BOEBEL RD

Provider Business Mailing Address
First Line	:	1703 MANANA ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78730-4237
Country	:	US
Telephone Number	:	512-750-2348
Fax Number	:

Provider Business Practice Location Address
First Line	:	1703 MANANA ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78730-4237
Country	:	US
Telephone Number	:	512-750-2348
Fax Number	:

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

Provider Enumeration Date	:	02/20/2014
Last Update Date	:	04/14/2020

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