Healthcare Provider Details

I. General information

NPI: 1649544065
Provider Name (Legal Business Name): REBECCA EDWARDS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. REBECCA GOFF

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 CONGRESS STREET SUITE 320
PORTLAND ME
04102
US

IV. Provider business mailing address

301C US ROUTE 1
SCARBOROUGH ME
04074-9701
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-5522
  • Fax: 207-662-5527
Mailing address:
  • Phone: 207-396-8600
  • Fax: 207-396-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI1089
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: