Healthcare Provider Details

I. General information

NPI: 1598366049
Provider Name (Legal Business Name): OSWALD DIGESTIVE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

2893 KNOX AVE S APT 607
MINNEAPOLIS MN
55408-1865
US

IV. Provider business mailing address

2893 KNOX AVE S APT 607
MINNEAPOLIS MN
55408-1865
US

V. Phone/Fax

Practice location:
  • Phone: 612-805-7142
  • Fax:
Mailing address:
  • Phone: 612-805-7142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY OSWALD
Title or Position: DIETITIAN & FOUNDER
Credential: RDN
Phone: 612-805-7142