Healthcare Provider Details

I. General information

NPI: 1598640930
Provider Name (Legal Business Name): ALICIA REARDON NDTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2025
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 PLEASANT AVE S
PARK RAPIDS MN
56470-1431
US

IV. Provider business mailing address

17664 SUNNY HILL DR
LAPORTE MN
56461-5084
US

V. Phone/Fax

Practice location:
  • Phone: 218-616-3377
  • Fax:
Mailing address:
  • Phone: 952-486-2231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number86170823
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: