Healthcare Provider Details

I. General information

NPI: 1922093038
Provider Name (Legal Business Name): VIVIAN DALE SKAINS R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
US

IV. Provider business mailing address

416 PEBBLE DR
JONESBORO LA
71251-5100
US

V. Phone/Fax

Practice location:
  • Phone: 318-327-4000
  • Fax:
Mailing address:
  • Phone: 318-259-1204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number642
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: