Healthcare Provider Details

I. General information

NPI: 1477204618
Provider Name (Legal Business Name): SARA CAITLIN KITCHEN KOCH MPH, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 TURNER MCCALL BLVD SW
ROME GA
30165-5621
US

IV. Provider business mailing address

19 AUTUMN PL NE
WHITE GA
30184-2776
US

V. Phone/Fax

Practice location:
  • Phone: 706-509-6090
  • Fax:
Mailing address:
  • Phone: 678-372-7679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD005262
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: