MEDICARE: COOK LEARN 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1067445	OTHER		COMMISSION ON DIETETIC REGISTRATION

General Provider Information

NPI Number	:	1164874434
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COOK LEARN LIVE

Provider Business Mailing Address
First Line	:	9 BURLING AVE
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10605-3508
Country	:	US
Telephone Number	:	917-834-5596
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 BURLING AVE
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10605-3508
Country	:	US
Telephone Number	:	917-834-5596
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JENNA S LEBOWICH
Credential	:	RDN
Telephone Number	:	917-834-5596

Provider Enumeration Date	:	07/11/2016
Last Update Date	:	07/11/2016

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Directions to “COOK LEARN LIVE ” Practice Location

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