Healthcare Provider Details

I. General information

NPI: 1740889781
Provider Name (Legal Business Name): GEORGIA ELIZABETH BROWN REGISTERED DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE PROFESSIONAL CT
BEND OR
97701-6063
US

IV. Provider business mailing address

20770 EMPIRE AVE APT 140
BEND OR
97701-5000
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-6313
  • Fax:
Mailing address:
  • Phone: 650-218-9702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number10209301
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: