Healthcare Provider Details

I. General information

NPI: 1891736187
Provider Name (Legal Business Name): SANDRA GAY MINIX RD, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA GAY TUCKER RD, CD

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST BLVD DEPT OF NUTRITION
ELKHART IN
46514-2483
US

IV. Provider business mailing address

600 EAST BLVD
ELKHART IN
46514-2483
US

V. Phone/Fax

Practice location:
  • Phone: 574-524-7474
  • Fax: 574-296-6504
Mailing address:
  • Phone: 574-524-7474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD002665
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: