Healthcare Provider Details

I. General information

NPI: 1235179797
Provider Name (Legal Business Name): ANGELO CAPOZZOLI RD, CSR, LD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1462 MONTREAL RD SUITE 203
TUCKER GA
30084-6929
US

IV. Provider business mailing address

1462 MONTREAL RD SUITE 203
TUCKER GA
30084-6929
US

V. Phone/Fax

Practice location:
  • Phone: 770-674-5458
  • Fax: 770-674-1871
Mailing address:
  • Phone: 770-674-5458
  • Fax: 770-674-1871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDN0000001874
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberLD001724
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: