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NPI Code Detail

MEDICARE: KATHLEEN SUE DETAMORE RD, LD

MEDICARE: KATHLEEN SUE DETAMORE RD, LD
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
1133V00000XRegistered Dietitian5709OH

General Provider Information

NPI Number : 1922022979
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATHLEEN SUE DETAMORE RD, LD
Provider Business Mailing Address
First Line : 56 TOWNSHIP ROAD 900
Second Line :
City : WEST SALEM
State : OH
Zip : 44287-8729
Country : US
Telephone Number : 419-869-7527
Fax Number :
Provider Business Practice Location Address
First Line : 55 W WATERLOO RD
Second Line :
City : AKRON
State : OH
Zip : 44319-1116
Country : US
Telephone Number : 330-724-7715
Fax Number : 330-724-1080
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/26/2006
Last Update Date : 07/08/2007

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Directions to “ KATHLEEN SUE DETAMORE RD, LD” Practice Location

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