MEDICARE: MRS. KRISTINE S WILLIAMS RD LD

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	468	NM

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	HSZ196	OTHER	NM	MEDICARE PART B

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508832791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTINE S WILLIAMS RD LD

Provider Business Mailing Address
First Line	:	43 OPHIR DR
Second Line	:
City	:	DURANGO
State	:	CO
Zip	:	81301
Country	:	US
Telephone Number	:	970-382-0927
Fax Number	:

Provider Business Practice Location Address
First Line	:	12000 STONE LAKE RD
Second Line	:	DULCE HEALTH CENTER
City	:	DULCE
State	:	NM
Zip	:	87528
Country	:	US
Telephone Number	:	505-759-3291
Fax Number	:	505-759-7289

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

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	06/03/2008

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