MEDICARE: SHASTA NUTRITION SERVICES

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	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)

General Provider Information

NPI Number	:	1578635439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHASTA NUTRITION SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 993503
Second Line	:
City	:	REDDING
State	:	CA
Zip	:	96099-3503
Country	:	US
Telephone Number	:	530-355-5820
Fax Number	:

Provider Business Practice Location Address
First Line	:	9225 PLACER RD
Second Line	:
City	:	REDDING
State	:	CA
Zip	:	96001-2364
Country	:	US
Telephone Number	:	530-355-5820
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. KEVIN MERL DICKINSON
Credential	:
Telephone Number	:	530-355-5820

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	08/22/2020

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