MEDICARE: REBECCA JANE DISTER R.D., L.D.

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	1014155	OH

General Provider Information

NPI Number	:	1356618011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA JANE DISTER R.D., L.D.

Provider Business Mailing Address
First Line	:	13273 SPRUCE RUN DR APT 311
Second Line	:
City	:	NORTH ROYALTON
State	:	OH
Zip	:	44133-4284
Country	:	US
Telephone Number	:	440-227-4775
Fax Number	:

Provider Business Practice Location Address
First Line	:	13273 SPRUCE RUN DR APT 311
Second Line	:
City	:	NORTH ROYALTON
State	:	OH
Zip	:	44133-4284
Country	:	US
Telephone Number	:	440-227-4775
Fax Number	:

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

Provider Enumeration Date	:	11/23/2011
Last Update Date	:	11/23/2011

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