Healthcare Provider Details

I. General information

NPI: 1306447271
Provider Name (Legal Business Name): RACHEL ANN STARK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2645 VIKINGS CIR
EAGAN MN
55121-1000
US

IV. Provider business mailing address

4200 DAHLBERG DR STE 300
GOLDEN VALLEY MN
55422-4841
US

V. Phone/Fax

Practice location:
  • Phone: 952-456-7650
  • Fax:
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4446
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: