MEDICARE: TRUDY BERNICE EKSTROM CN, MS, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist	H11-00044-C-096986	NV

General Provider Information

NPI Number	:	1952573453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRUDY BERNICE EKSTROM CN, MS, PHD

Provider Business Mailing Address
First Line	:	2620 REGATTA DR
Second Line	:	SUITE 102
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-6891
Country	:	US
Telephone Number	:	702-363-9260
Fax Number	:	702-658-6721

Provider Business Practice Location Address
First Line	:	2620 REGATTA DR
Second Line	:	SUITE 102
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-6891
Country	:	US
Telephone Number	:	702-363-9260
Fax Number	:	702-658-6721

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2008
Last Update Date	:	03/25/2008

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