Healthcare Provider Details

I. General information

NPI: 1184430654
Provider Name (Legal Business Name): GEORGIA OKUMURA RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 LONGVIEW DR
COATESVILLE PA
19320-2220
US

IV. Provider business mailing address

2434 LONGVIEW DR
COATESVILLE PA
19320-2220
US

V. Phone/Fax

Practice location:
  • Phone: 484-885-5658
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN008153
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: