Healthcare Provider Details

I. General information

NPI: 1710145958
Provider Name (Legal Business Name): FAHIMAH YAZDANFARD CALLAHAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 05/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14832 MAIN ST. USRENAL CARETRI-COUNTY DIALYSIS
LYTLE TX
78052
US

IV. Provider business mailing address

14 KNIGHTS PEAK
SAN ANTONIO TX
78254-2511
US

V. Phone/Fax

Practice location:
  • Phone: 830-772-5784
  • Fax: 830-772-5793
Mailing address:
  • Phone: 210-872-6105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT 80799
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: