MEDICARE: STACY M. SMITH 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	LD002671	GA

General Provider Information

NPI Number	:	1255532495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY M. SMITH RD,LD

Provider Business Mailing Address
First Line	:	3501 WALDROP TRL
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30034-7463
Country	:	US
Telephone Number	:	404-229-2768
Fax Number	:

Provider Business Practice Location Address
First Line	:	261 PARKWAY DR NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30312-1210
Country	:	US
Telephone Number	:	404-265-6468
Fax Number	:

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

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	07/08/2007

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