MEDICARE: MS. SUSAN PEACOCK M.S.,R.D.,LDN

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	133V00000X	Registered Dietitian	ND3521	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699816504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN PEACOCK M.S.,R.D.,LDN

Provider Business Mailing Address
First Line	:	100 WATERWAY DR S APT 203
Second Line	:
City	:	LANTANA
State	:	FL
Zip	:	33462-1827
Country	:	US
Telephone Number	:	561-758-1734
Fax Number	:	561-540-5186

Provider Business Practice Location Address
First Line	:	2240 W WOOLBRIGHT RD STE 305
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33426-6363
Country	:	US
Telephone Number	:	561-758-1734
Fax Number	:	561-540-5186

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

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	06/18/2022

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