Provider Demographics
NPI:1164890935
Name:KUBETIN, SARA (RD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:KUBETIN
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 1:130 QUINCY AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2803
Mailing Address - Country:US
Mailing Address - Phone:508-941-7250
Mailing Address - Fax:
Practice Address - Street 1:130 QUINCY AVE FL 2
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2803
Practice Address - Country:US
Practice Address - Phone:508-941-7250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA86014100133V00000X
MA3830133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered