Provider Demographics
NPI:1649547407
Name:CHAN, CAROL ELIZABETH (RD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ELIZABETH
Last Name:CHAN
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 1:59 BRAINERD RD
Mailing Address - Street 2:#413
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-4528
Mailing Address - Country:US
Mailing Address - Phone:714-319-4868
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1001162133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered