MEDICARE: DAPHNNE BALIZAN RD, LD

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	39354-DI-0	NV

General Provider Information

NPI Number	:	1730681255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAPHNNE BALIZAN RD, LD

Provider Business Mailing Address
First Line	:	6671 LAS VEGAS BLVD S STE 210
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-3273
Country	:	US
Telephone Number	:	702-761-6911
Fax Number	:

Provider Business Practice Location Address
First Line	:	6671 LAS VEGAS BLVD S STE 210
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-3273
Country	:	US
Telephone Number	:	702-761-6911
Fax Number	:

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

Provider Enumeration Date	:	02/28/2018
Last Update Date	:	03/05/2020

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