MEDICARE: MRS. PAYAL MODY RD, CNSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	953243	IL
2	133VN1006X	Metabolic Nutrition Registered Dietitian	1858150	MD
3	133VN1004X	Pediatric Nutrition Registered Dietitian	133VN1004X	NJ
4	133VN1005X	Renal Nutrition Registered Dietitian	133VN1005X	NJ

General Provider Information

NPI Number	:	1073875068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PAYAL MODY RD, CNSC

Provider Business Mailing Address
First Line	:	1117 BIRCHWOOD CT
Second Line	:
City	:	NORTH BRUNSWICK
State	:	NJ
Zip	:	08902-1924
Country	:	US
Telephone Number	:	732-991-0775
Fax Number	:

Provider Business Practice Location Address
First Line	:	1117 BIRCHWOOD CT
Second Line	:
City	:	NORTH BRUNSWICK
State	:	NJ
Zip	:	08902-1924
Country	:	US
Telephone Number	:	732-991-0775
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2012
Last Update Date	:	09/26/2012

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