Healthcare Provider Details

I. General information

NPI: 1093806952
Provider Name (Legal Business Name): SUVASINI MCCORMICK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

IV. Provider business mailing address

5717 E GABLE AVE
MESA AZ
85206-6715
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-5551
  • Fax:
Mailing address:
  • Phone: 480-275-2422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberOO361183
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: