Provider Demographics
NPI:1487734000
Name:VINCENT, REBECCA (RD, LD, CLC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:VINCENT
Suffix:
Gender:F
Credentials:RD, LD, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ZENA DR
Mailing Address - Street 2:P. O. BOX 665
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30121-2482
Mailing Address - Country:US
Mailing Address - Phone:770-382-1920
Mailing Address - Fax:770-387-3999
Practice Address - Street 1:100 ZENA DR
Practice Address - Street 2:100 ZENA DRIVE
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-2482
Practice Address - Country:US
Practice Address - Phone:770-382-1920
Practice Address - Fax:770-387-3999
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000436133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBKPMedicare ID - Type Unspecified