=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881015113
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICIA ELENA FARHAT MPH, RD, LD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2014
-----------------------------------------------------
Last Update Date | 01/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1935 MEDICAL DISTRICT DR CLINICAL NUTRITION
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75235-7701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-456-3264
-----------------------------------------------------
Fax | 214-456-6287
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 714 LIBERTY ST APT 2812
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75204-8716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-588-9532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133VN1004X
-----------------------------------------------------
Taxonomy Name | Pediatric Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 1039352
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------