MEDICARE: MS. JOSEPHINE THOMASON 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	915167	FL
2	133V00000X	Registered Dietitian	ND6152	FL

General Provider Information

NPI Number	:	1578033700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JOSEPHINE THOMASON RD, LD

Provider Business Mailing Address
First Line	:	11 EVANSMILL LN
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-6214
Country	:	US
Telephone Number	:	386-569-5448
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 EVANSMILL LN
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-6214
Country	:	US
Telephone Number	:	386-569-5448
Fax Number	:

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

Provider Enumeration Date	:	11/30/2018
Last Update Date	:	11/30/2018

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