MEDICARE: MRS. ELISA A SMITH RDN LDN

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	L004938	NC

General Provider Information

NPI Number	:	1679086565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELISA A SMITH RDN LDN

Provider Business Mailing Address
First Line	:	2941 BATTLEGROUND AVE UNIT 39194
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27438-1004
Country	:	US
Telephone Number	:	336-601-6287
Fax Number	:

Provider Business Practice Location Address
First Line	:	229 N GREENE ST
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27401-2410
Country	:	US
Telephone Number	:	336-601-6287
Fax Number	:

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

Provider Enumeration Date	:	11/14/2017
Last Update Date	:	11/15/2018

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