Healthcare Provider Details

I. General information

NPI: 1568555175
Provider Name (Legal Business Name): JILL S. SHRIVER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MT. CARMEL WAY
PITTSBURG KS
66762
US

IV. Provider business mailing address

P.O. POX 1266
PITTSBURG KS
66762
US

V. Phone/Fax

Practice location:
  • Phone: 620-232-0133
  • Fax: 620-232-0163
Mailing address:
  • Phone: 620-232-0133
  • Fax: 620-232-0163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1139
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: