Basic Information
| Provider Information | |||||||||
| NPI: | 1003010521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UEDA | ||||||||
| FirstName: | KEIKO | ||||||||
| MiddleName: | |||||||||
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| Credential: | MPH, RD, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 279 WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021701021 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 750 WASHINGTON ST | ||||||||
| Address2: | TNEMC BOX#434 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021111526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176365458 | ||||||||
| FaxNumber: | 6176360745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 547 | MA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 547 | 01 | MA | STATE LICENSE | OTHER |