Provider Demographics
NPI:1477937464
Name:VACEK, KELLI W (MA, RD, LD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:W
Last Name:VACEK
Suffix:
Gender:F
Credentials:MA, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 IH 10 N
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1051
Mailing Address - Country:US
Mailing Address - Phone:409-454-0417
Mailing Address - Fax:
Practice Address - Street 1:990 IH 10 N
Practice Address - Street 2:SUITE 215
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1051
Practice Address - Country:US
Practice Address - Phone:409-454-0417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered