Basic Information
| Provider Information | |||||||||
| NPI: | 1144688870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SARSOZA | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SALT | ||||||||
| OtherFirstName: | MARISA | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331814 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1919 E THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850167710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029333366 | ||||||||
| FaxNumber: | 6029334264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2016 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 897659 | AZ | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 122312 | 05 | AZ | MEDICAID |