MEDICARE: MRS. LACIE MARIE PETERSON RD, CD, CDE

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	6120423-4901	UT

General Provider Information

NPI Number	:	1316052780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LACIE MARIE PETERSON RD, CD, CDE

Provider Business Mailing Address
First Line	:	2016 STRATFORD DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1711
Country	:	US
Telephone Number	:	801-699-5753
Fax Number	:	801-585-5906

Provider Business Practice Location Address
First Line	:	615 ARAPEEN DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1267
Country	:	US
Telephone Number	:	801-587-3961
Fax Number	:	801-585-5906

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

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	11/09/2010

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