Healthcare Provider Details

I. General information

NPI: 1306414818
Provider Name (Legal Business Name): EVAN M SAILOR RD, LD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2021
Last Update Date: 06/12/2021
Certification Date: 06/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9640 COMMERCE DR STE 412
CARMEL IN
46032-7638
US

IV. Provider business mailing address

11386 TEAL ST APT 1507
FISHERS IN
46038-2479
US

V. Phone/Fax

Practice location:
  • Phone: 317-662-0082
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37002963A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: