Healthcare Provider Details

I. General information

NPI: 1720181118
Provider Name (Legal Business Name): SANDRA GRAHAM PECK EDM RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 GREAT ROAD SUITE 10
ACTON MA
01720
US

IV. Provider business mailing address

481 GREAT ROAD SUITE 10
ACTON MA
01720
US

V. Phone/Fax

Practice location:
  • Phone: 978-266-1576
  • Fax:
Mailing address:
  • Phone: 978-266-1576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number60
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: