=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629510268
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA MICHELLE EWING RD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2016
-----------------------------------------------------
Last Update Date | 11/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 321 MITCHELL AVE
-----------------------------------------------------
City | BATESVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47006-8909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-934-6624
-----------------------------------------------------
Fax | 812-933-5252
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3189 MCCOWAN DR
-----------------------------------------------------
City | TAYLOR MILL
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41015-4438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 86062879
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------