Healthcare Provider Details

I. General information

NPI: 1245422302
Provider Name (Legal Business Name): IRENE RUTH ALTON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 CESAR CHAVEZ ST
W. ST. PAUL MN
55107-2226
US

IV. Provider business mailing address

153 CESAR CHAVEZ ST
W. ST. PAUL MN
55107-2226
US

V. Phone/Fax

Practice location:
  • Phone: 651-222-1816
  • Fax: 651-222-1305
Mailing address:
  • Phone: 651-222-1816
  • Fax: 651-222-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberN138
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: