MEDICARE: DIANA M CROXTON RD

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	133VN1005X	Renal Nutrition Registered Dietitian	ND208	FL

General Provider Information

NPI Number	:	1508974411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA M CROXTON RD

Provider Business Mailing Address
First Line	:	663 SW WOODSIDE DR
Second Line	:
City	:	PALM CITY
State	:	FL
Zip	:	34990-4333
Country	:	US
Telephone Number	:	772-283-4954
Fax Number	:

Provider Business Practice Location Address
First Line	:	2348 SE OCEAN BLVD
Second Line	:	TREASURE COAST KIDNEY CTR - NORTH - CKD SERVICES
City	:	STUART
State	:	FL
Zip	:	34996-3310
Country	:	US
Telephone Number	:	772-286-2470
Fax Number	:	772-223-5829

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

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	11/27/2007

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