Basic Information
| Provider Information | |||||||||
| NPI: | 1558363440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANBORN | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | GEHRT | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1823 COLLEGE AVE. | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665023381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857763322 | ||||||||
| FaxNumber: | 7855875447 | ||||||||
| Practice Location | |||||||||
| Address1: | 1105 SUNSET AVE. | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665023381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857763322 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 08/11/2010 | ||||||||
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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 | 583 | KS | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 100426580A | 05 | KS | MEDICAID |