=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396183190
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEA POD NUTRITION AND LACTATION SUPPORT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2013
-----------------------------------------------------
Last Update Date | 06/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1164 N HIGHLAND AVE NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30306-3448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-607-6052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5493
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31107-0493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-607-6052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | ALICIA C SIMPSON
-----------------------------------------------------
Credential | MS, RD, LD
-----------------------------------------------------
Telephone | 678-607-6052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | LD004064
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------