MEDICARE: RACHAEL WALLACE HARTLEY 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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1568628998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHAEL WALLACE HARTLEY RD

Provider Business Mailing Address
First Line	:	1313 MAPLE ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29205-1253
Country	:	US
Telephone Number	:	803-381-3304
Fax Number	:

Provider Business Practice Location Address
First Line	:	1898 CALHOUN ST STE 8
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-2650
Country	:	US
Telephone Number	:	803-381-3304
Fax Number	:

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

Provider Enumeration Date	:	08/05/2008
Last Update Date	:	04/11/2016

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