Healthcare Provider Details

I. General information

NPI: 1871926477
Provider Name (Legal Business Name): MEGAN BREKKE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 PINE TREE DR
BIGFORK MN
56628
US

IV. Provider business mailing address

26303 TROUT LAKE RD
BOVEY MN
55709-8602
US

V. Phone/Fax

Practice location:
  • Phone: 218-743-4349
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3223
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: