MEDICARE: CARLY AUSTIN RD, LD

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	86051182	TX
2	133V00000X	Registered Dietitian	DT86364	TX
3	133V00000X	Registered Dietitian	86051182	CA

General Provider Information

NPI Number	:	1922519321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY AUSTIN RD, LD

Provider Business Mailing Address
First Line	:	543 COUNTRY CLUB DR STE B516
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-0637
Country	:	US
Telephone Number	:	805-796-8436
Fax Number	:

Provider Business Practice Location Address
First Line	:	543 COUNTRY CLUB DR STE B516
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-0637
Country	:	US
Telephone Number	:	805-796-8436
Fax Number	:

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

Provider Enumeration Date	:	10/12/2017
Last Update Date	:	02/08/2024

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