MEDICARE: TAVIA MARIE VITAL RN, 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	163WD0400X	Diabetes Educator Registered Nurse	041390337	IL

General Provider Information

NPI Number	:	1508145756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAVIA MARIE VITAL RN, CDE

Provider Business Mailing Address
First Line	:	2560 24TH ST
Second Line	:	SUITE 102
City	:	ROCK ISLAND
State	:	IL
Zip	:	61201-5357
Country	:	US
Telephone Number	:	309-788-0014
Fax Number	:	309-793-3092

Provider Business Practice Location Address
First Line	:	2560 24TH ST
Second Line	:	SUITE 102
City	:	ROCK ISLAND
State	:	IL
Zip	:	61201-5357
Country	:	US
Telephone Number	:	309-788-0014
Fax Number	:	309-793-3092

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

Provider Enumeration Date	:	08/05/2011
Last Update Date	:	08/05/2011

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