Healthcare Provider Details

I. General information

NPI: 1649540345
Provider Name (Legal Business Name): LINDSAY PAIGE BULLOCK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LINDSAY PAIGE MCDANIEL RD

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 COOKS HILL RD
CENTRALIA WA
98531-9073
US

IV. Provider business mailing address

519 NW QUINCY PL
CHEHALIS WA
98532-1629
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-6778
  • Fax: 360-736-6552
Mailing address:
  • Phone: 360-736-6778
  • Fax: 360-736-6552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number1006104
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60220652
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: