Healthcare Provider Details

I. General information

NPI: 1902148646
Provider Name (Legal Business Name): DORIAN VENABLE II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAJO ROUTE 64
TSAILE AZ
86556
US

IV. Provider business mailing address

PO BOX PH
CHINLE AZ
86503-8000
US

V. Phone/Fax

Practice location:
  • Phone: 928-724-3612
  • Fax: 928-724-3671
Mailing address:
  • Phone: 928-674-7166
  • Fax: 928-674-7705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT07319
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: