MEDICARE: MRS. CARRIE GUSTAFSON RDN, 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	DT86371	TX
2	133VN1005X	Renal Nutrition Registered Dietitian	DT86371	TX

General Provider Information

NPI Number	:	1306435169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARRIE GUSTAFSON RDN, LD

Provider Business Mailing Address
First Line	:	530 PARADISE HLS
Second Line	:
City	:	NEW BRAUNFELS
State	:	TX
Zip	:	78132-2320
Country	:	US
Telephone Number	:	520-560-5583
Fax Number	:

Provider Business Practice Location Address
First Line	:	915 S LAREDO ST UNIT 200
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78204-3211
Country	:	US
Telephone Number	:	520-560-5583
Fax Number	:

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

Provider Enumeration Date	:	01/15/2021
Last Update Date	:	01/19/2021

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