MEDICARE: BONITA LILLIE RD

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	2004009119	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G02785D01	OTHER		MEDICARE PTAN

General Provider Information

NPI Number	:	1134305857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONITA LILLIE RD

Provider Business Mailing Address
First Line	:	5412 CASTLE BAR LN
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22315-5519
Country	:	US
Telephone Number	:	703-879-5160
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 EISENHOWER AVE
Second Line	:	SUITE 200
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-4698
Country	:	US
Telephone Number	:	703-519-0901
Fax Number	:	703-519-0902

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

Provider Enumeration Date	:	01/11/2008
Last Update Date	:	09/18/2008

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Directions to “ BONITA LILLIE RD” Practice Location

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