Healthcare Provider Details

I. General information

NPI: 1598862724
Provider Name (Legal Business Name): PEDIATRIC EDUCATION DIETITIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 CLARKSON RD
ELLISVILLE MO
63011-2245
US

IV. Provider business mailing address

254 CLARKSON RD
ELLISVILLE MO
63011-2245
US

V. Phone/Fax

Practice location:
  • Phone: 636-227-7337
  • Fax:
Mailing address:
  • Phone: 636-227-7337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number2001004908
License Number StateMO

VIII. Authorized Official

Name: BARBARA K LINNEMAN
Title or Position: OWNER
Credential: MS, RD, LD
Phone: 636-227-7337