MEDICARE: LISA MARIE BRESLIN 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	133N00000X	Nutritionist
2	133V00000X	Registered Dietitian	007715	NY

General Provider Information

NPI Number	:	1598276321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE BRESLIN RD

Provider Business Mailing Address
First Line	:	1200 BROWN STREET
Second Line	:	HRHCARE, INC. CREDENTIALING DEPT
City	:	PEEKSKILL
State	:	NY
Zip	:	10566-2913
Country	:	US
Telephone Number	:	914-734-8858
Fax Number	:	914-734-8786

Provider Business Practice Location Address
First Line	:	75 WASHINGTON ST
Second Line	:
City	:	POUGHKEEPSIE
State	:	NY
Zip	:	12601-2303
Country	:	US
Telephone Number	:	845-790-7990
Fax Number	:	845-790-9036

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

Provider Enumeration Date	:	10/19/2017
Last Update Date	:	10/19/2017

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