MEDICARE: MRS. CORY BROOKE GRIZZARD R.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		VA

General Provider Information

NPI Number	:	1487038980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CORY BROOKE GRIZZARD R.D.

Provider Business Mailing Address
First Line	:	1601 BROAD ROCK BLVD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23224-4923
Country	:	US
Telephone Number	:	804-371-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 BROAD ROCK BLVD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23224-4923
Country	:	US
Telephone Number	:	804-371-8000
Fax Number	:

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

Provider Enumeration Date	:	07/14/2015
Last Update Date	:	12/08/2015

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