Healthcare Provider Details

I. General information

NPI: 1861510711
Provider Name (Legal Business Name): NANCY J KEIM RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 NORTH HIGHWAY 25
BLOOMFIELD MO
63825-0000
US

IV. Provider business mailing address

PO BOX 23
LEOPOLD MO
63760-0023
US

V. Phone/Fax

Practice location:
  • Phone: 573-238-1620
  • Fax: 567-568-4736
Mailing address:
  • Phone: 573-568-4593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2005020910
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: