MEDICARE: TAD JACOB TAGGART RD, CD

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		WI

General Provider Information

NPI Number	:	1508535006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAD JACOB TAGGART RD, CD

Provider Business Mailing Address
First Line	:	1657 LENWOOD AVE APT 7
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54303-5397
Country	:	US
Telephone Number	:	920-246-4886
Fax Number	:

Provider Business Practice Location Address
First Line	:	1710 LAWRENCE DR STE 200
Second Line	:
City	:	DE PERE
State	:	WI
Zip	:	54115-9195
Country	:	US
Telephone Number	:	920-570-6339
Fax Number	:

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

Provider Enumeration Date	:	09/08/2021
Last Update Date	:	09/08/2021

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Directions to “ TAD JACOB TAGGART RD, CD” Practice Location

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