MEDICARE: MRS. KIM M VIVES-LAWAL MS. RD. CDN

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	00720405	NY

General Provider Information

NPI Number	:	1609123454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIM M VIVES-LAWAL MS. RD. CDN

Provider Business Mailing Address
First Line	:	100 CASALS PL
Second Line	:	4G
City	:	BRONX
State	:	NY
Zip	:	10475-3002
Country	:	US
Telephone Number	:	718-379-0436
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 CASALS PL
Second Line	:	4G
City	:	BRONX
State	:	NY
Zip	:	10475-3002
Country	:	US
Telephone Number	:	718-379-0436
Fax Number	:

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

Provider Enumeration Date	:	08/11/2012
Last Update Date	:	08/11/2012

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