Healthcare Provider Details

I. General information

NPI: 1730219494
Provider Name (Legal Business Name): ROSEMARY MOULD ERTEL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROSEMARY SARAH MOULD RD

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 DESALES AVE MEMORIAL HOSPIAL- DIABETES CENTER
CHATTANOOGA TN
37404-1161
US

IV. Provider business mailing address

86 RAINBOW CIR
CHATTANOOGA TN
37405-2320
US

V. Phone/Fax

Practice location:
  • Phone: 423-495-7971
  • Fax: 423-495-7978
Mailing address:
  • Phone: 423-267-5935
  • Fax: 423-495-7978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDN0000000880
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: