Healthcare Provider Details

I. General information

NPI: 1497776611
Provider Name (Legal Business Name): GRETCHEN BEA ROCKSTAD LRD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 4TH ST NW
MAHNOMEN MN
56557-4208
US

IV. Provider business mailing address

410 4TH ST NW
MAHNOMEN MN
56557-4208
US

V. Phone/Fax

Practice location:
  • Phone: 218-835-2514
  • Fax: 218-835-2720
Mailing address:
  • Phone: 218-835-2514
  • Fax: 218-835-2720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1291
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: