MEDICARE: BEVERLY DIANE PATTON 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	DT03961	TX

General Provider Information

NPI Number	:	1770632028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVERLY DIANE PATTON RD

Provider Business Mailing Address
First Line	:	340 TREELINE PARK APT 1514
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-1844
Country	:	US
Telephone Number	:	210-822-9445
Fax Number	:

Provider Business Practice Location Address
First Line	:	2950 KOEHLER RD
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-7535
Country	:	US
Telephone Number	:	210-822-9445
Fax Number	:

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

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	07/08/2007

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