Healthcare Provider Details

I. General information

NPI: 1386140614
Provider Name (Legal Business Name): ADAM PRUETT RDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BOND AVE
EAST SAINT LOUIS IL
62207-2326
US

IV. Provider business mailing address

5116 EAGLE WING CT
EUREKA MO
63025-4043
US

V. Phone/Fax

Practice location:
  • Phone: 618-332-5458
  • Fax:
Mailing address:
  • Phone: 636-584-9153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2008029468
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.007263
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: