MEDICARE: MARIN CLEMSON 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	86065552	AZ

General Provider Information

NPI Number	:	1811456502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIN CLEMSON RD

Provider Business Mailing Address
First Line	:	2500 W UTOPIA RD STE 100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-4172
Country	:	US
Telephone Number	:	623-683-4462
Fax Number	:	623-683-4963

Provider Business Practice Location Address
First Line	:	10210 N 92ND ST STE 101
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85258-4523
Country	:	US
Telephone Number	:	480-882-7460
Fax Number	:	480-391-3898

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

Provider Enumeration Date	:	03/13/2019
Last Update Date	:	03/13/2019

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