Healthcare Provider Details

I. General information

NPI: 1962664938
Provider Name (Legal Business Name): REBECCA K PEREZ RD/LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3568 PIN OAK CIR
DORAVILLE GA
30340-2514
US

IV. Provider business mailing address

3568 PIN OAK CIR
DORAVILLE GA
30340-2514
US

V. Phone/Fax

Practice location:
  • Phone: 770-446-7971
  • Fax:
Mailing address:
  • Phone: 770-446-7971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberLD2026
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: