Provider Demographics
NPI:1780867549
Name:VIDAL, KAREN L (MS, RD)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:L
Last Name:VIDAL
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6350 LAKE OCONEE PKWY
Mailing Address - Street 2:SUITE 102, PMB 89
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-6433
Mailing Address - Country:US
Mailing Address - Phone:706-485-1298
Mailing Address - Fax:
Practice Address - Street 1:6350 LAKE OCONEE PKWY
Practice Address - Street 2:SUITE 102, PMB 89
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-6433
Practice Address - Country:US
Practice Address - Phone:706-485-1298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001664133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered