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Dietary & Nutritional Service Providers Dietitian, Registered Nutrition, Renal

Provider NPI: 1679035612

Provider Information:
Gender: M
Not Sole Proprietor

Practice Location:
Tel: 314-651-4100  Fax: --

Business Mailing Address:
307 FRONT ST  ENERGY, IL 62933-5032 US
Tel: 618-364-5672  Fax: --

NPI Information:
NPI: 1679035612
Entity Type: Individual


PrimaryCodeCategory/DescriptionStateLicense Number
Y133VN1005XDietary & Nutritional Service Providers
Dietitian, Registered
Nutrition, Renal

Other Provider Identifiers:


American Medical Association 2012 taxonomy code information

Code: 133VN1005X





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