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NPI Code Detail

MEDICARE: SARAH SHEPHERD RD

MEDICARE: SARAH SHEPHERD 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
1133V00000XRegistered Dietitian

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11063705OTHERCOCOMMISSION ON DIETETIC REGISTRATION

General Provider Information

NPI Number : 1164783882
Entity Type Code : Individual
Provider Name (Legal Business Name) : SARAH SHEPHERD RD
Provider Business Mailing Address
First Line : 443 HIGHWAY 105
Second Line :
City : PALMER LAKE
State : CO
Zip : 80133-9003
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 443 HIGHWAY 105
Second Line :
City : PALMER LAKE
State : CO
Zip : 80133-9003
Country : US
Telephone Number : 719-660-2694
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/30/2012
Last Update Date : 05/22/2015

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