Provider Demographics
NPI:1194819581
Name:PEROVICH, SARA J (RD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:J
Last Name:PEROVICH
Suffix:
Gender:F
Credentials:RD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5654
Practice Address - Street 1:8300 CONSTITUTION AVE NE
Practice Address - Street 2:KASEMAN HOSPITAL FOOD AND NUTRITION
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7613
Practice Address - Country:US
Practice Address - Phone:505-291-2625
Practice Address - Fax:505-291-2446
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM6133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM301891Medicare PIN
NM77223357Medicare PIN