1114153277 NPI number — LYDIA AULTMAN REGISTERED DIETITIAN

Table of content: LYDIA AULTMAN REGISTERED DIETITIAN (NPI 1114153277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114153277 NPI number — LYDIA AULTMAN REGISTERED DIETITIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AULTMAN
Provider First Name:
LYDIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
REGISTERED DIETITIAN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114153277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 TEBEAU ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAYCROSS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31501-6357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-287-4271
Provider Business Mailing Address Fax Number:
912-338-6400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 TEBEAU ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYCROSS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31501-6357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-287-4271
Provider Business Practice Location Address Fax Number:
912-338-6400
Provider Enumeration Date:
06/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  006433 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com