MEDICARE: MRS. SUE MCKENZIE TALBERT RD CDE LDN

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	L001793	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	710000239	OTHER	NC	MEDICARE RAILROAD CARRIER

General Provider Information

NPI Number	:	1861590333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUE MCKENZIE TALBERT RD CDE LDN

Provider Business Mailing Address
First Line	:	612 COLLEGE STREET
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28540
Country	:	US
Telephone Number	:	910-347-2154
Fax Number	:	910-347-2789

Provider Business Practice Location Address
First Line	:	1450 LEONARD ST NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5515
Country	:	US
Telephone Number	:	616-774-8789
Fax Number	:

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	02/02/2021

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