Healthcare Provider Details

I. General information

NPI: 1376673996
Provider Name (Legal Business Name): ROBERTA H SACCONE R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N JORDAN AVENUE
BLOOMINGTON IN
47405-3191
US

IV. Provider business mailing address

2908 KINGS CT
BLOOMINGTON IN
47401-2409
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-7338
  • Fax: 812-855-4628
Mailing address:
  • Phone: 812-331-1320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37001747A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: