Provider Demographics
NPI:1720065717
Name:FARKAS, MARY ETHEL (RD/MNT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ETHEL
Last Name:FARKAS
Suffix:
Gender:F
Credentials:RD/MNT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ETHEL
Other - Last Name:BOCKWINKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 MADRONE ST
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-4225
Mailing Address - Country:US
Mailing Address - Phone:707-456-3132
Mailing Address - Fax:707-456-3022
Practice Address - Street 1:1 MADRONE ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-4225
Practice Address - Country:US
Practice Address - Phone:707-456-3132
Practice Address - Fax:707-456-3022
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22432ZMedicare UPIN