Healthcare Provider Details

I. General information

NPI: 1003312885
Provider Name (Legal Business Name): TRACY STROTHER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 S LEMAY AVE STE B
FORT COLLINS CO
80525
US

IV. Provider business mailing address

1308 WOODVIEW PL
FORT COLLINS CO
80526-3047
US

V. Phone/Fax

Practice location:
  • Phone: 970-231-3411
  • Fax:
Mailing address:
  • Phone: 970-231-3411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number931125
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: