MEDICARE: CARLY FAZIO RD, LDN, CPT

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	ND8673	FL

General Provider Information

NPI Number	:	1639632805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY FAZIO RD, LDN, CPT

Provider Business Mailing Address
First Line	:	6283 LIBERTY HILL PT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-1128
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6283 LIBERTY HILL PT
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-1128
Country	:	US
Telephone Number	:	954-599-1144
Fax Number	:

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

Provider Enumeration Date	:	04/12/2019
Last Update Date	:	04/12/2019

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