MEDICARE: MARI L CHAMBERLAIN 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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1669567228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARI L CHAMBERLAIN RD

Provider Business Mailing Address
First Line	:	1270 MONTEVUE LN
Second Line	:	AREA B, AFMSA/SGRTE
City	:	FORT DETRICK
State	:	MD
Zip	:	21702-5058
Country	:	US
Telephone Number	:	301-619-8601
Fax Number	:	301-619-8638

Provider Business Practice Location Address
First Line	:	1270 MONTEVUE LN
Second Line	:	AREA B, AFMSA/SGRTE
City	:	FORT DETRICK
State	:	MD
Zip	:	21702-5058
Country	:	US
Telephone Number	:	301-619-8601
Fax Number	:	301-619-8638

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	12/19/2007

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Directions to “ MARI L CHAMBERLAIN RD” Practice Location

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