=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700900958
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERTA DIANE PARKER CADC LL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2914 COLD SPRINGS RD STE A
-----------------------------------------------------
City | PLACERVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95667-4220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-642-1715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7017 SERVICE CT APT B
-----------------------------------------------------
City | DIAMOND SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95619-9277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-295-1249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A8449706
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------