Provider Demographics
NPI:1730274887
Name:DEPARTMENT OF VETERANS AFFAIRS
Entity type:Organization
Organization Name:DEPARTMENT OF VETERANS AFFAIRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RD CNSD
Authorized Official - Phone:601-362-4471
Mailing Address - Street 1:1500 EAST WOODROW WILSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5199
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:601-368-4483
Practice Address - Street 1:1500 EAST WOODROW WILSON DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5199
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-368-4483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
R422643133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty