Healthcare Provider Details

I. General information

NPI: 1699066209
Provider Name (Legal Business Name): DOROTHY DITTMER KENDA RD LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2011
Last Update Date: 04/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MEMPHIS ST
BOGALUSA LA
70427-3862
US

IV. Provider business mailing address

400 MEMPHIS ST
BOGALUSA LA
70427-3862
US

V. Phone/Fax

Practice location:
  • Phone: 985-730-7177
  • Fax: 985-730-6898
Mailing address:
  • Phone: 985-730-7177
  • Fax: 985-730-6898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2190
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: