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General NPI Number Information
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NPI Number | 1245348408
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Entity Type | Individual
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Provider Name | GEORGE MARK CORAM RD
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Gender | Male
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Dates
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Enumeration Date | 08/28/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | NAVAHCS 500 N HWY 89
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City | PRESCOTT
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State | AZ
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Zip | 86313
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Country | US
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Telephone | 928-445-4860
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Fax | 928-717-7423
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Provider Business Mailing Address
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Address Line | 11850 E ARABIAN LN
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City | DEWEY
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State | AZ
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Zip | 86327-6001
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Country | US
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Telephone | 928-445-4860
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Fax | 928-717-7423
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 11982
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License Number State | IL
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