Healthcare Provider Details

I. General information

NPI: 1225097116
Provider Name (Legal Business Name): REBECCA MILDRED GOODELL R.D.L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W FOUNTAIN ST
ALBERT LEA MN
56007-2437
US

IV. Provider business mailing address

718 PARK AVE
ALBERT LEA MN
56007-4465
US

V. Phone/Fax

Practice location:
  • Phone: 507-373-2384
  • Fax:
Mailing address:
  • Phone: 507-373-1905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1126
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: