Provider Demographics
NPI:1770275646
Name:SANDERS, WILLIAM ROBERT (MS, RD, LD, ACSM-CPT)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:ROBERT
Last Name:SANDERS
Suffix:
Gender:M
Credentials:MS, RD, LD, ACSM-CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 HORN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125-1527
Mailing Address - Country:US
Mailing Address - Phone:812-449-7686
Mailing Address - Fax:
Practice Address - Street 1:130 HORN AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-1527
Practice Address - Country:US
Practice Address - Phone:812-449-7686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20211046142133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered