MEDICARE: CHASLEY TESS FORTUNE 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	86174251	TX

General Provider Information

NPI Number	:	1841812443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHASLEY TESS FORTUNE RD

Provider Business Mailing Address
First Line	:	9734 ALISA BROOKE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78254-6100
Country	:	US
Telephone Number	:	210-838-0420
Fax Number	:

Provider Business Practice Location Address
First Line	:	9618 HUEBNER RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-1660
Country	:	US
Telephone Number	:	210-634-2200
Fax Number	:	210-634-2201

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

Provider Enumeration Date	:	05/18/2020
Last Update Date	:	11/27/2023

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