=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518402445
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY C KOBERLEIN L.D./N.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2017
-----------------------------------------------------
Last Update Date | 01/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1021 S PROSPECT AVE APT O
-----------------------------------------------------
City | HARTVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44632-9480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-388-6869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1021 S PROSPECT AVE APT O
-----------------------------------------------------
City | HARTVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44632-9480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-388-6869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | LD7930
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------