=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184229841
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIAMI DIETITIANS GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2020
-----------------------------------------------------
Last Update Date | 10/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11413 SW 246TH TER
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33032-4655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-592-1520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11413 SW 246TH TER
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33032-4655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-592-1520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | MARIA EUGENIA RICCOMBENI
-----------------------------------------------------
Credential | RD LD N
-----------------------------------------------------
Telephone | 786-592-1520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------