Healthcare Provider Details

I. General information

NPI: 1063979961
Provider Name (Legal Business Name): PRAIRIE VIEW CREATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8508 N PRAIRIE VW
PRESCOTT VALLEY AZ
86315-9089
US

IV. Provider business mailing address

PO BOX 10214
PRESCOTT AZ
86304-0214
US

V. Phone/Fax

Practice location:
  • Phone: 928-772-8652
  • Fax: 928-772-8078
Mailing address:
  • Phone: 928-772-8652
  • Fax: 928-772-8078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: CHAD HETHERWICK
Title or Position: REGISTERED DIETITIAN NUTRITIONIST
Credential: MS, RD
Phone: 928-772-8652