Healthcare Provider Details

I. General information

NPI: 1821109422
Provider Name (Legal Business Name): MARLA RAE LOVE LRD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARLA RAE MILLER LRD

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S MINNESOTA STREET
CROOKSTON MN
56716
US

IV. Provider business mailing address

PO BOX 606
CROOKSTON MN
56716
US

V. Phone/Fax

Practice location:
  • Phone: 218-281-9100
  • Fax: 218-281-9189
Mailing address:
  • Phone: 218-281-9100
  • Fax: 218-281-9189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number432
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: