MEDICARE: KIMBERLY HOGUE RD, LD

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	DT07168	TX

General Provider Information

NPI Number	:	1205159308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY HOGUE RD, LD

Provider Business Mailing Address
First Line	:	4337 SUMMER STAR LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4935
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4337 SUMMER STAR LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4935
Country	:	US
Telephone Number	:	817-343-1997
Fax Number	:	817-562-4337

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

Provider Enumeration Date	:	03/04/2010
Last Update Date	:	03/04/2010

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