Healthcare Provider Details

I. General information

NPI: 1568761880
Provider Name (Legal Business Name): MAUREEN A GEBOY RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 03/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 JACKSON ST
NEWNAN GA
30263-1572
US

IV. Provider business mailing address

137 JACKSON ST
NEWNAN GA
30263-1572
US

V. Phone/Fax

Practice location:
  • Phone: 770-254-7400
  • Fax:
Mailing address:
  • Phone: 770-254-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD002545
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: