MEDICARE: DESERT SAGE NUTRITION CENTER

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

General Provider Information

NPI Number	:	1851868921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT SAGE NUTRITION CENTER

Provider Business Mailing Address
First Line	:	4007 E CHARTER OAK RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-7470
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4007 E CHARTER OAK RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-7470
Country	:	US
Telephone Number	:	480-332-3098
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARILYN CRYAN
Credential	:	RD
Telephone Number	:	480-332-3098

Provider Enumeration Date	:	10/26/2018
Last Update Date	:	10/26/2018

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