Healthcare Provider Details

I. General information

NPI: 1861827321
Provider Name (Legal Business Name): RENEE KATHRYN FAVILLE RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2013
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 FAIRVIEW ST
SILVERTON OR
97381-1917
US

IV. Provider business mailing address

4430 GREGORY CT SE
SALEM OR
97302-4822
US

V. Phone/Fax

Practice location:
  • Phone: 503-873-1518
  • Fax:
Mailing address:
  • Phone: 971-218-3630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberLD-D-10158473
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: