MEDICARE: CHANIKA TERI MOSES SMTIH

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
2	133VN1501X	Sports Dietetics Nutrition Registered Dietitian

General Provider Information

NPI Number	:	1598481848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANIKA TERI MOSES SMTIH

Provider Business Mailing Address
First Line	:	3505 MYTH LN
Second Line	:
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-4524
Country	:	US
Telephone Number	:	281-451-6339
Fax Number	:

Provider Business Practice Location Address
First Line	:	620 BOWERS BLVD
Second Line	:	313C
City	:	HUNTSVILLE
State	:	TX
Zip	:	77845
Country	:	US
Telephone Number	:	936-294-2798
Fax Number	:

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

Provider Enumeration Date	:	10/18/2022
Last Update Date	:	10/18/2022

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