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NPI Code Detail

MEDICARE: MRS. CARYL B. FAIRFULL RD

MEDICARE: MRS. CARYL B. FAIRFULL 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

General Provider Information

NPI Number : 1255484374
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. CARYL B. FAIRFULL RD
Provider Business Mailing Address
First Line : 11622 CEMENT HILL RD
Second Line :
City : NEVADA CITY
State : CA
Zip : 95959-9061
Country : US
Telephone Number : 530-470-0870
Fax Number : 530-470-0870
Provider Business Practice Location Address
First Line : 11622 CEMENT HILL RD
Second Line :
City : NEVADA CITY
State : CA
Zip : 95959-9061
Country : US
Telephone Number : 530-470-0870
Fax Number : 530-470-0870
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/19/2007
Last Update Date : 07/08/2007

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