MEDICARE: MRS. SANDRA MINNICK OLIVERIO MS, RD, CD

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	133VN1005X	Renal Nutrition Registered Dietitian	37000553A	IN

General Provider Information

NPI Number	:	1912347717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SANDRA MINNICK OLIVERIO MS, RD, CD

Provider Business Mailing Address
First Line	:	2325 18TH ST
Second Line	:	SUITE 210
City	:	COLUMBUS
State	:	IN
Zip	:	47201-5388
Country	:	US
Telephone Number	:	812-375-0272
Fax Number	:	812-375-1093

Provider Business Practice Location Address
First Line	:	2325 18TH ST
Second Line	:	SUITE 210
City	:	COLUMBUS
State	:	IN
Zip	:	47201-5388
Country	:	US
Telephone Number	:	812-375-0272
Fax Number	:	812-375-1093

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

Provider Enumeration Date	:	06/26/2013
Last Update Date	:	06/26/2013

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