MEDICARE: LILLIAN AINSWORTH GLUSENKAMP R.D.

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	D0130	MS

General Provider Information

NPI Number	:	1821279522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILLIAN AINSWORTH GLUSENKAMP R.D.

Provider Business Mailing Address
First Line	:	1421 JOLLY RD
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39705-2928
Country	:	US
Telephone Number	:	662-251-6896
Fax Number	:

Provider Business Practice Location Address
First Line	:	1421 JOLLY RD
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39705-2928
Country	:	US
Telephone Number	:	662-251-6896
Fax Number	:

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

Provider Enumeration Date	:	11/21/2007
Last Update Date	:	04/18/2017

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