MEDICARE: DEVON RAGOLIA VISALLI 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
1	133V00000X	Registered Dietitian	DX6184	MD
2	133V00000X	Registered Dietitian	DN-0011072	DE

General Provider Information

NPI Number	:	1295416881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVON RAGOLIA VISALLI RD

Provider Business Mailing Address
First Line	:	104 ROCK AVE
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19804-3827
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 ROCK AVE
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19804-3827
Country	:	US
Telephone Number	:	302-757-9868
Fax Number	:

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

Provider Enumeration Date	:	07/27/2023
Last Update Date	:	07/27/2023

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Directions to “ DEVON RAGOLIA VISALLI RD” Practice Location

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