MEDICARE: EAT TO LIVE

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	LDN00559	RI

General Provider Information

NPI Number	:	1154605103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAT TO LIVE

Provider Business Mailing Address
First Line	:	195 BROADWAY
Second Line	:
City	:	NEWPORT
State	:	RI
Zip	:	02840-2610
Country	:	US
Telephone Number	:	401-486-7089
Fax Number	:	401-619-0949

Provider Business Practice Location Address
First Line	:	195 BROADWAY
Second Line	:
City	:	NEWPORT
State	:	RI
Zip	:	02840-2610
Country	:	US
Telephone Number	:	401-486-7089
Fax Number	:	401-619-0949

Authorized Official
Title or Position	:	DIETITIAN/OWNER
Name	:	MELISSA KIRDZIK
Credential	:	MS, RD, LDN
Telephone Number	:	401-486-7089

Provider Enumeration Date	:	10/07/2011
Last Update Date	:	10/07/2011

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Directions to “EAT TO LIVE ” Practice Location

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