MEDICARE: LUCILLE HELEN COOKE 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

General Provider Information

NPI Number	:	1831629021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUCILLE HELEN COOKE RD

Provider Business Mailing Address
First Line	:	5802 E SOUTH WILSHIRE DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85711-4540
Country	:	US
Telephone Number	:	520-870-2870
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 N TUCSON BLVD STE 6
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85716-3404
Country	:	US
Telephone Number	:	520-829-9635
Fax Number	:

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

Provider Enumeration Date	:	06/19/2017
Last Update Date	:	06/19/2017

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