Basic Information
| Provider Information | |||||||||
| NPI: | 1881944213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DITTMER | ||||||||
| FirstName: | CALA | ||||||||
| MiddleName: | ELKINS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELKINS | ||||||||
| OtherFirstName: | CALA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 221 TECHNOLOGY PKWY NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7622351000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1825 MARTHA BERRY BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063788189 | ||||||||
| FaxNumber: | 7062388037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2012 | ||||||||
| LastUpdateDate: | 02/07/2019 | ||||||||
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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 | LD003776 | GA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 003128800A | 05 | GA | MEDICAID | 003128800B | 05 | GA | MEDICAID | 003128800E | 05 | GA | MEDICAID |