Healthcare Provider Details

I. General information

NPI: 1669467593
Provider Name (Legal Business Name): SALLY D. LINCOLN R.D., L.D., M.S.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 MEDICAL DR
LAGRANGE GA
30240-4137
US

IV. Provider business mailing address

7727 HILLDALE DR
COLUMBUS GA
31909-1627
US

V. Phone/Fax

Practice location:
  • Phone: 706-845-4035
  • Fax:
Mailing address:
  • Phone: 706-660-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1967
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: