MEDICARE: MRS. KRISTIN A. KWAK M.S., R.D., L.D.N.

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	DN001674	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	723015	OTHER		DIETETIC REGISTRATION NUM

General Provider Information

NPI Number	:	1710101324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTIN A. KWAK M.S., R.D., L.D.N.

Provider Business Mailing Address
First Line	:	PO BOX 404
Second Line	:
City	:	HOLICONG
State	:	PA
Zip	:	18928-0404
Country	:	US
Telephone Number	:	267-879-5148
Fax Number	:

Provider Business Practice Location Address
First Line	:	4950 YORK RD
Second Line	:	SUITE 2D-1
City	:	HOLICONG
State	:	PA
Zip	:	18928-6000
Country	:	US
Telephone Number	:	267-879-5148
Fax Number	:

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

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	07/08/2007

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