Healthcare Provider Details

I. General information

NPI: 1518177799
Provider Name (Legal Business Name): CHRISTINE MARIE TWAIT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINE MARIE CHAMBERLAIN RD

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 CHURCH ST SE BOYNTON HEALTH SERVICE
MINNEAPOLIS MN
55455-0340
US

IV. Provider business mailing address

410 CHURCH ST SE
MINNEAPOLIS MN
55455-0340
US

V. Phone/Fax

Practice location:
  • Phone: 612-625-8400
  • Fax: 612-625-1434
Mailing address:
  • Phone: 612-625-8400
  • Fax: 612-625-1434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2647
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: