=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487280327
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADISHING RECOVERY NUTRITION COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2020
-----------------------------------------------------
Last Update Date | 03/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9535 FOREST LN
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75243-5900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-454-0213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1508 FLAMINGO DR
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76012-5513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, REGISTERED DIETITIAN
-----------------------------------------------------
Name | NICHOLETTE SHAWN
-----------------------------------------------------
Credential | RD, LD
-----------------------------------------------------
Telephone | 469-454-0213
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------