Healthcare Provider Details

I. General information

NPI: 1649497009
Provider Name (Legal Business Name): CAROLYN CHU MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 WASHINGTON ST
DORCHESTER CENTER MA
02124-3510
US

IV. Provider business mailing address

76 ELM ST G08
JAMAICA PLAIN MA
02130-2892
US

V. Phone/Fax

Practice location:
  • Phone: 617-825-9660
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number967783
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: