Basic Information
| Provider Information | |||||||||
| NPI: | 1629109178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADAY | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 208 | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855500208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284752371 | ||||||||
| FaxNumber: | 9284757370 | ||||||||
| Practice Location | |||||||||
| Address1: | 223 CIBEQUE CIRCLE ROAD | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855500208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284752371 | ||||||||
| FaxNumber: | 9284757370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 809443 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 169194 | 05 | AZ | MEDICAID |