Healthcare Provider Details

I. General information

NPI: 1124173885
Provider Name (Legal Business Name): LAUREN TINA DIMITROV R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7011 A C SKINNER PKWY SUITE 160
JACKSONVILLE FL
32256-6954
US

IV. Provider business mailing address

PO BOX 551308
JACKSONVILLE FL
32255-1308
US

V. Phone/Fax

Practice location:
  • Phone: 904-493-3333
  • Fax: 904-493-2222
Mailing address:
  • Phone: 904-493-3333
  • Fax: 904-493-2222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND 5498
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: