Basic Information
| Provider Information | |||||||||
| NPI: | 1144622994 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEGALL | ||||||||
| FirstName: | CAROLINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3209 S 23RD ST | ||||||||
| Address2: | STE 340 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984051602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535032598 | ||||||||
| FaxNumber: | 2534040506 | ||||||||
| Practice Location | |||||||||
| Address1: | 2202 S CEDAR ST | ||||||||
| Address2: | STE 330 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984052318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532725127 | ||||||||
| FaxNumber: | 2532720811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2014 | ||||||||
| LastUpdateDate: | 11/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DI60482894 | WA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | G001045700 | 01 | WA | MEDICARE (PIERCE) | OTHER | G8933865 | 01 | WA | MDCR PTAN (KING) | OTHER | G000188100 | 01 | WA | MEDICARE (KING) | OTHER | G8933866 | 01 | WA | MDCR PTAN (PIERCE) | OTHER |