Provider Demographics
NPI:1114672060
Name:BOBO, BENITA LIGIA (RD)
Entity Type:Individual
Prefix:
First Name:BENITA
Middle Name:LIGIA
Last Name:BOBO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 RIVER SHOALS CT
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-2124
Mailing Address - Country:US
Mailing Address - Phone:404-804-1300
Mailing Address - Fax:
Practice Address - Street 1:4204 RIVER SHOALS CT
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-2124
Practice Address - Country:US
Practice Address - Phone:404-804-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD006035133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered