Healthcare Provider Details

I. General information

NPI: 1316172026
Provider Name (Legal Business Name): BECKY J OVERHOLT RD, CSO, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

IV. Provider business mailing address

200 HIGH PARK AVENUE
GOSHEN IN
46526-4361
US

V. Phone/Fax

Practice location:
  • Phone: 574-535-2868
  • Fax:
Mailing address:
  • Phone: 574-535-2868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37001104A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: