MEDICARE: ELIZABETH WAGNER RD, CCN

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	133N00000X	Nutritionist
2	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1134302565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH WAGNER RD, CCN

Provider Business Mailing Address
First Line	:	1224 10TH ST STE 207
Second Line	:
City	:	CORONADO
State	:	CA
Zip	:	92118-3420
Country	:	US
Telephone Number	:	619-437-6600
Fax Number	:	619-437-6603

Provider Business Practice Location Address
First Line	:	1224 10TH ST STE 207
Second Line	:
City	:	CORONADO
State	:	CA
Zip	:	92118-3420
Country	:	US
Telephone Number	:	619-437-6600
Fax Number	:	619-437-6603

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

Provider Enumeration Date	:	12/07/2007
Last Update Date	:	04/01/2011

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