MEDICARE: A & B NUTRITION EDUCATION, LLC

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	527790

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	423167	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1215247663
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A & B NUTRITION EDUCATION, LLC

Provider Business Mailing Address
First Line	:	5802 N. 25TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-2842
Country	:	US
Telephone Number	:	602-451-6826
Fax Number	:

Provider Business Practice Location Address
First Line	:	5802 N 25TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-2842
Country	:	US
Telephone Number	:	602-451-6826
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. LEZLI R. STONE
Credential	:	R.D.
Telephone Number	:	602-451-6826

Provider Enumeration Date	:	10/19/2010
Last Update Date	:	10/19/2010

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