Healthcare Provider Details

I. General information

NPI: 1417233156
Provider Name (Legal Business Name): RENEE A MATGOURANIS LD/RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 TROY RD
SPRINGFIELD OH
45504-4335
US

IV. Provider business mailing address

31737 LEEWARD CT
AVON LAKE OH
44012-2926
US

V. Phone/Fax

Practice location:
  • Phone: 937-342-8800
  • Fax: 937-342-8805
Mailing address:
  • Phone: 440-933-2234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2296
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: