MEDICARE: MS. MYRIAN JEANETTE CHAVEZ MS, RD, LD, 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	DT07511	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	961737	OTHER	TX	REGISTERED DIETITIAN
2	2011-0463	OTHER	TX	CERTIFIED DIABETES EDUCATOR

General Provider Information

NPI Number	:	1467765032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MYRIAN JEANETTE CHAVEZ MS, RD, LD, CDE

Provider Business Mailing Address
First Line	:	7834 BROADWAY ST
Second Line	:	#601
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-2568
Country	:	US
Telephone Number	:	210-372-2997
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 BROOKLYN AVENUE
Second Line	:	SUITE 240
City	:	SAN ANTONIO
State	:	TX
Zip	:	78212-4830
Country	:	US
Telephone Number	:	210-225-4511
Fax Number	:	210-225-4514

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

Provider Enumeration Date	:	07/23/2010
Last Update Date	:	11/17/2010

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