MEDICARE: ELEANOR ELLISON MS, 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	LD005270	GA

General Provider Information

NPI Number	:	1578101168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELEANOR ELLISON MS, RD, LD

Provider Business Mailing Address
First Line	:	2175 LONGWOOD DR
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36830-7124
Country	:	US
Telephone Number	:	334-728-1899
Fax Number	:

Provider Business Practice Location Address
First Line	:	8208 MADISON DR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30346-2459
Country	:	US
Telephone Number	:	334-728-1899
Fax Number	:

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

Provider Enumeration Date	:	12/15/2019
Last Update Date	:	12/15/2019

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