Healthcare Provider Details

I. General information

NPI: 1871127290
Provider Name (Legal Business Name): KAYLA GIRGEN RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE N
SAINT CLOUD MN
56303-2735
US

IV. Provider business mailing address

1725 7TH ST SW
ROCHESTER MN
55902-0904
US

V. Phone/Fax

Practice location:
  • Phone: 320-240-2828
  • Fax:
Mailing address:
  • Phone: 507-272-2756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4303
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: