MEDICARE: TERRYL OWENS MPH, 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	85002123	NY

General Provider Information

NPI Number	:	1720259823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRYL OWENS MPH, RD

Provider Business Mailing Address
First Line	:	5 CROSS LN
Second Line	:
City	:	GLEN HEAD
State	:	NY
Zip	:	11545-1109
Country	:	US
Telephone Number	:	646-462-5714
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 CROSS LN
Second Line	:
City	:	GLEN HEAD
State	:	NY
Zip	:	11545-1109
Country	:	US
Telephone Number	:	646-462-5714
Fax Number	:

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

Provider Enumeration Date	:	03/17/2008
Last Update Date	:	03/17/2008

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