Healthcare Provider Details

I. General information

NPI: 1235623711
Provider Name (Legal Business Name): KAY VAVRINA RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

IV. Provider business mailing address

8431 NOELLA WAY
SAN ANTONIO TX
78240-4577
US

V. Phone/Fax

Practice location:
  • Phone: 210-743-8604
  • Fax: 210-702-4567
Mailing address:
  • Phone: 904-718-4210
  • Fax: 210-702-4302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT82257
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDT82257
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: