MEDICARE: SHANA S TATUM 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	DT85629	TX

General Provider Information

NPI Number	:	1922576875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANA S TATUM RD

Provider Business Mailing Address
First Line	:	725 GARDEN OAKS BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-5407
Country	:	US
Telephone Number	:	713-252-5549
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 W 12TH ST STE B
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-6990
Country	:	US
Telephone Number	:	713-868-4372
Fax Number	:

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

Provider Enumeration Date	:	11/08/2018
Last Update Date	:	11/08/2018

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Directions to “ SHANA S TATUM RD” Practice Location

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