MEDICARE: RACHEL D HEINEN 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	133NN1002X	Nutrition Education Nutritionist	DT83490	TX
2	133V00000X	Registered Dietitian	DT83490	TX
3	133VN1006X	Metabolic Nutrition Registered Dietitian	DT83490	TX

General Provider Information

NPI Number	:	1376911651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHEL D HEINEN RDN, LD

Provider Business Mailing Address
First Line	:	8112 BROKEN ARROW RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-1291
Country	:	US
Telephone Number	:	817-793-0115
Fax Number	:

Provider Business Practice Location Address
First Line	:	8112 BROKEN ARROW RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-1291
Country	:	US
Telephone Number	:	817-793-0115
Fax Number	:

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

Provider Enumeration Date	:	09/03/2015
Last Update Date	:	09/03/2015

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