Healthcare Provider Details

I. General information

NPI: 1528848660
Provider Name (Legal Business Name): LARISSA ROSE EADEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2023
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2802 BRIGHTWATER CT
FORT COLLINS CO
80524-6716
US

IV. Provider business mailing address

2802 BRIGHTWATER CT
FORT COLLINS CO
80524-6716
US

V. Phone/Fax

Practice location:
  • Phone: 941-330-4884
  • Fax:
Mailing address:
  • Phone: 941-330-4884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: