Healthcare Provider Details

I. General information

NPI: 1679028617
Provider Name (Legal Business Name): ALICIA LUFTMAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 BEAM AVE SUITE 302
MAPLEWOOD MN
55109-1163
US

IV. Provider business mailing address

2439 UNITY AVE N
GOLDEN VALLEY MN
55422-3449
US

V. Phone/Fax

Practice location:
  • Phone: 651-227-6351
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3009
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: