Healthcare Provider Details

I. General information

NPI: 1679862940
Provider Name (Legal Business Name): SARAH JOAN TRAVIS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 N DECATUR RD
DECATUR GA
30033-5307
US

IV. Provider business mailing address

2165 N DECATUR RD
DECATUR GA
30033-5307
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-8610
  • Fax: 404-778-8562
Mailing address:
  • Phone: 404-778-8610
  • Fax: 404-778-8562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD003417
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: