Healthcare Provider Details

I. General information

NPI: 1144622994
Provider Name (Legal Business Name): CAROLINE SEGALL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 S CEDAR ST STE 330
TACOMA WA
98405-2318
US

IV. Provider business mailing address

3209 S 23RD ST STE 340
TACOMA WA
98405-1602
US

V. Phone/Fax

Practice location:
  • Phone: 253-272-5127
  • Fax: 253-272-0811
Mailing address:
  • Phone: 253-503-2598
  • Fax: 253-404-0506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60482894
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: