MEDICARE: LINZY JAE PETERSON 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	86084652	AZ

General Provider Information

NPI Number	:	1851883060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINZY JAE PETERSON RD

Provider Business Mailing Address
First Line	:	9305 W THOMAS RD STE 360
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85037-3367
Country	:	US
Telephone Number	:	623-327-8200
Fax Number	:

Provider Business Practice Location Address
First Line	:	9305 W THOMAS RD STE 360
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85037-3367
Country	:	US
Telephone Number	:	623-327-8200
Fax Number	:

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

Provider Enumeration Date	:	06/04/2018
Last Update Date	:	06/04/2018

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