Basic Information
| Provider Information | |||||||||
| NPI: | 1730274887 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPARTMENT OF VETERANS AFFAIRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 EAST WOODROW WILSON DRIVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
| FaxNumber: | 6013684483 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 EAST WOODROW WILSON DRIVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
| FaxNumber: | 6013684483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 08/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIETITIAN | ||||||||
| AuthorizedOfficialTelephone: | 6013624471 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | R.D. C.N.S.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | R422643 | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.