MEDICARE: CANDISE JORDAN FENTON R.D.

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	1061751	AL

General Provider Information

NPI Number	:	1720369085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDISE JORDAN FENTON R.D.

Provider Business Mailing Address
First Line	:	2506 BALBOA ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-6934
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2506 BALBOA ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-6934
Country	:	US
Telephone Number	:	719-425-5793
Fax Number	:

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

Provider Enumeration Date	:	08/31/2011
Last Update Date	:	08/31/2011

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