MEDICARE: LESLIE REID IODICE RD, L/DN

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	ND1113	FL

General Provider Information

NPI Number	:	1861784217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE REID IODICE RD, L/DN

Provider Business Mailing Address
First Line	:	4470 COUNTRY RD
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32934-8467
Country	:	US
Telephone Number	:	321-255-9800
Fax Number	:	321-751-1145

Provider Business Practice Location Address
First Line	:	2092 SARNO RD
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32935-3077
Country	:	US
Telephone Number	:	321-255-9800
Fax Number	:	321-751-1145

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

Provider Enumeration Date	:	05/04/2011
Last Update Date	:	12/05/2011

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