MEDICARE: EMILY CHEATHAM 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	86325783	CA

General Provider Information

NPI Number	:	1770342586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY CHEATHAM RD

Provider Business Mailing Address
First Line	:	100 WOODED GLEN CT
Second Line	:
City	:	WINDSOR
State	:	CA
Zip	:	95492-8062
Country	:	US
Telephone Number	:	707-479-8467
Fax Number	:

Provider Business Practice Location Address
First Line	:	170 WINDSOR RIVER RD STE WEST
Second Line	:
City	:	WINDSOR
State	:	CA
Zip	:	95492-9204
Country	:	US
Telephone Number	:	707-385-9746
Fax Number	:

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

Provider Enumeration Date	:	03/14/2024
Last Update Date	:	03/14/2024

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