Healthcare Provider Details

I. General information

NPI: 1467555680
Provider Name (Legal Business Name): DIANE SMOGOR M.N.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8051 S EMERSON AVE SUITE 340
INDIANAPOLIS IN
46237-8600
US

IV. Provider business mailing address

PO BOX 66664048
INDIANAPOLIS IN
46266-4048
US

V. Phone/Fax

Practice location:
  • Phone: 317-865-5904
  • Fax: 317-865-5321
Mailing address:
  • Phone: 317-780-3333
  • Fax: 317-780-3345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number37001004A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: