MEDICARE: MS. MARY ELLEN VIVRETT 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	133NN1002X	Nutrition Education Nutritionist	DT02946	TX
2	133NN1002X	Nutrition Education Nutritionist	16160	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	16160	OTHER	TX	REGISTERED DIETITIAN
2	DT02946	OTHER	TX	LICENSED DIETITIAN

General Provider Information

NPI Number	:	1356773683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY ELLEN VIVRETT R.D., L.D.

Provider Business Mailing Address
First Line	:	3725 LONG AVE
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77706-4728
Country	:	US
Telephone Number	:	409-651-3489
Fax Number	:	409-899-0448

Provider Business Practice Location Address
First Line	:	3725 LONG AVE
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77706-4728
Country	:	US
Telephone Number	:	409-651-3489
Fax Number	:	409-898-0448

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

Provider Enumeration Date	:	08/09/2013
Last Update Date	:	07/01/2015

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