Healthcare Provider Details

I. General information

NPI: 1902634801
Provider Name (Legal Business Name): INTEGRATED RD CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19128 66TH AVE N
CORCORAN MN
55340-2001
US

IV. Provider business mailing address

19128 66TH AVE N
CORCORAN MN
55340-2001
US

V. Phone/Fax

Practice location:
  • Phone: 320-237-5952
  • Fax:
Mailing address:
  • Phone: 320-237-5952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JANA L MARTIN
Title or Position: REGISTERED DIEITIAN
Credential: MS.RDN,LD
Phone: 320-237-5952