MEDICARE: THE GUT RD, LLC

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	ND 7447	FL

General Provider Information

NPI Number	:	1932653615
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE GUT RD, LLC

Provider Business Mailing Address
First Line	:	440 45TH AVE
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32968-1866
Country	:	US
Telephone Number	:	772-971-9006
Fax Number	:

Provider Business Practice Location Address
First Line	:	3190 SUNTREE BLVD STE 101
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-5741
Country	:	US
Telephone Number	:	772-971-9006
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTI N BUCK
Credential	:	RDN, LD
Telephone Number	:	772-971-9006

Provider Enumeration Date	:	08/10/2016
Last Update Date	:	08/10/2016

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