Healthcare Provider Details

I. General information

NPI: 1558721506
Provider Name (Legal Business Name): BETHANY LUSK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 12/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 QUINCY ST
BROCKTON MA
02302-2967
US

IV. Provider business mailing address

189 QUINCY ST
BROCKTON MA
02302-2967
US

V. Phone/Fax

Practice location:
  • Phone: 508-588-6700
  • Fax: 508-584-3010
Mailing address:
  • Phone: 508-588-6700
  • Fax: 508-584-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: