Healthcare Provider Details

I. General information

NPI: 1942605738
Provider Name (Legal Business Name): EMILY JO HEGE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WASHINGTON RD
WEST POINT NY
10996-1109
US

IV. Provider business mailing address

2817 REILLY ST ATTN MCXC NCD
FORT BRAGG NC
28310-7301
US

V. Phone/Fax

Practice location:
  • Phone: 845-938-6661
  • Fax:
Mailing address:
  • Phone: 336-813-0350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL004795
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: