Healthcare Provider Details

I. General information

NPI: 1104907609
Provider Name (Legal Business Name): SOUTHERN OREGON NUTRITION & DIABETES TRAINING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 E MAIN ST SUITE C
MEDFORD OR
97504-7133
US

IV. Provider business mailing address

825 E MAIN ST SUITE C
MEDFORD OR
97504-7133
US

V. Phone/Fax

Practice location:
  • Phone: 541-245-0713
  • Fax: 541-779-3526
Mailing address:
  • Phone: 541-245-0713
  • Fax: 541-779-3526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number366
License Number StateOR

VIII. Authorized Official

Name: SUSAN L SPIVA
Title or Position: DIETITIAN/OWNER
Credential: RD, CDE
Phone: 541-245-0713