=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023282738
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA M. BRADT RD, CSR, CDN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2008
-----------------------------------------------------
Last Update Date | 05/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 DELAWARE AVE SUITE 100
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14202-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-903-3730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4490 SENECA ST
-----------------------------------------------------
City | WEST SENECA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14224-3139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-677-0102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133VN1005X
-----------------------------------------------------
Taxonomy Name | Renal Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 005925-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------