Healthcare Provider Details

I. General information

NPI: 1740617000
Provider Name (Legal Business Name): SARAH DESJARDIN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 CHARLTON RD
STURBRIDGE MA
01566
US

IV. Provider business mailing address

PO BOX 40
SOUTHBRIDGE MA
01550-0040
US

V. Phone/Fax

Practice location:
  • Phone: 508-347-7585
  • Fax: 508-347-7538
Mailing address:
  • Phone: 508-909-7799
  • Fax: 508-764-2432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4140
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: