Provider Demographics
NPI:1316477003
Name:EGGLESTONE, SEAN (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:EGGLESTONE
Suffix:
Gender:M
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 CARTER LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3327
Mailing Address - Country:US
Mailing Address - Phone:215-527-2522
Mailing Address - Fax:
Practice Address - Street 1:3333 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8800
Practice Address - Country:US
Practice Address - Phone:541-222-1227
Practice Address - Fax:541-222-1227
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86070019133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty