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NPI Code Detail

MEDICARE: LYNN STACY RD

MEDICARE: LYNN STACY RD
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
1133V00000XRegistered Dietitian360148CA

General Provider Information

NPI Number : 1407980444
Entity Type Code : Individual
Provider Name (Legal Business Name) : LYNN STACY RD
Provider Business Mailing Address
First Line : 770 10TH ST
Second Line :
City : ARCATA
State : CA
Zip : 95521-6210
Country : US
Telephone Number : 707-826-8610
Fax Number : 707-826-8623
Provider Business Practice Location Address
First Line : 770 10TH ST
Second Line :
City : ARCATA
State : CA
Zip : 95521-6210
Country : US
Telephone Number : 707-826-8610
Fax Number : 707-826-8623
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/14/2007
Last Update Date : 07/08/2007

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Directions to “ LYNN STACY RD” Practice Location

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