Healthcare Provider Details

I. General information

NPI: 1922041300
Provider Name (Legal Business Name): COURTNEY ROSE DRISCOLL RD LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 WAMPUM DRIVE
BREWSTER MA
02631
US

IV. Provider business mailing address

18 TERN ROAD
SOUTH YARMOUTH MA
05664
US

V. Phone/Fax

Practice location:
  • Phone: 508-896-9080
  • Fax: 508-896-3399
Mailing address:
  • Phone: 508-364-3549
  • Fax: 508-457-3977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2422
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: