Healthcare Provider Details

I. General information

NPI: 1780431890
Provider Name (Legal Business Name): ROSALIE OLIVIA GRANT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 RADIO DR
WOODBURY MN
55129-3237
US

IV. Provider business mailing address

3500 AMERICAN BLVD W STE 300
BLOOMINGTON MN
55431-4442
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-8807
  • Fax: 651-439-0232
Mailing address:
  • Phone: 952-512-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number5238
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number5686-29
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: