MEDICARE: DELORES PUFAHL R.D.,L.D.

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	1716	FL

General Provider Information

NPI Number	:	1659771905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DELORES PUFAHL R.D.,L.D.

Provider Business Mailing Address
First Line	:	7610 253RD ST E
Second Line	:
City	:	MYAKKA CITY
State	:	FL
Zip	:	34251-5883
Country	:	US
Telephone Number	:	941-915-8057
Fax Number	:	509-696-9631

Provider Business Practice Location Address
First Line	:	7610 253RD ST E
Second Line	:
City	:	MYAKKA CITY
State	:	FL
Zip	:	34251-5883
Country	:	US
Telephone Number	:	941-915-8057
Fax Number	:	509-696-9631

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

Provider Enumeration Date	:	08/23/2014
Last Update Date	:	08/23/2014

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