MEDICARE: JEAN R HALFORD

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	133VN1006X	Metabolic Nutrition Registered Dietitian	369684	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00103300	OTHER	ID	RAILROAD ME

General Provider Information

NPI Number	:	1669405932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEAN R HALFORD

Provider Business Mailing Address
First Line	:	2220 E 25TH ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7542
Country	:	US
Telephone Number	:	208-523-1122
Fax Number	:	208-523-2582

Provider Business Practice Location Address
First Line	:	2220 E 25TH ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7542
Country	:	US
Telephone Number	:	208-523-1122
Fax Number	:	208-523-2582

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

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	07/08/2007

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Directions to “ JEAN R HALFORD ” Practice Location

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