Healthcare Provider Details

I. General information

NPI: 1538395934
Provider Name (Legal Business Name): TERESA GAINES RD,LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA GAINES RD, LD

II. Dates (important events)

Enumeration Date: 05/31/2009
Last Update Date: 05/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE RD
TRIPLER ARMY MEDICAL CENTER HI
96859-5001
US

IV. Provider business mailing address

3219 SABRINA LN
COPPERAS COVE TX
76522-3715
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-2387
  • Fax:
Mailing address:
  • Phone: 254-289-0760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT80776
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: