Healthcare Provider Details

I. General information

NPI: 1215085972
Provider Name (Legal Business Name): ANGELA M SMITH RD, LD, CDM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N SANTIAM HWY
LEBANON OR
97355-4363
US

IV. Provider business mailing address

600 N 8TH ST
AUMSVILLE OR
97325-8959
US

V. Phone/Fax

Practice location:
  • Phone: 541-258-2101
  • Fax: 541-451-7862
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number743
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: