MEDICARE: GLYNNIS WOMACK 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	86031353
2	133V00000X	Registered Dietitian	86031353	CO

General Provider Information

NPI Number	:	1598125338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLYNNIS WOMACK RD

Provider Business Mailing Address
First Line	:	25 OAK MANOR CT
Second Line	:
City	:	CHICO
State	:	CA
Zip	:	95926-1779
Country	:	US
Telephone Number	:	530-828-5027
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 OAK MANOR CT
Second Line	:
City	:	CHICO
State	:	CA
Zip	:	95926-1779
Country	:	US
Telephone Number	:	530-828-5027
Fax Number	:

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

Provider Enumeration Date	:	03/06/2016
Last Update Date	:	08/08/2019

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