Healthcare Provider Details

I. General information

NPI: 1790843407
Provider Name (Legal Business Name): ELAINE A. HAGEN RD, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 10/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST BLVD NUTRITION SERVICES DEPARTMENT
ELKHART IN
46514-2483
US

IV. Provider business mailing address

PO BOX 660376 EGH INSURANCE PAYMENTS
INDIANAPOLIS IN
46266-0376
US

V. Phone/Fax

Practice location:
  • Phone: 574-523-3236
  • Fax: 574-296-6504
Mailing address:
  • Phone: 574-523-3148
  • Fax: 574-523-3492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number727380
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: