Basic Information
| Provider Information | |||||||||
| NPI: | 1902148646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VENABLE | ||||||||
| FirstName: | DORIAN | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | II | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX PH | ||||||||
| Address2: | |||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 865038000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747166 | ||||||||
| FaxNumber: | 9286747705 | ||||||||
| Practice Location | |||||||||
| Address1: | NAVAJO ROUTE 64 | ||||||||
| Address2: | |||||||||
| City: | TSAILE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287243612 | ||||||||
| FaxNumber: | 9287243671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2013 | ||||||||
| LastUpdateDate: | 03/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT07319 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 933052 | 01 | CDR | OTHER |