Healthcare Provider Details

I. General information

NPI: 1508037854
Provider Name (Legal Business Name): MARY E ORTWEIN R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 E VILLANOW ST
LA FAYETTE GA
30728-2618
US

IV. Provider business mailing address

603 E VILLANOW ST PO BOX 609
LA FAYETTE GA
30728-2618
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-5577
  • Fax: 706-638-5543
Mailing address:
  • Phone: 706-638-5577
  • Fax: 706-638-5543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberLD000701
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: