Healthcare Provider Details

I. General information

NPI: 1346697729
Provider Name (Legal Business Name): SAMANTHA ELISE HUFFORD RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 PARKVIEW DR
LATHROP MO
64465-9710
US

IV. Provider business mailing address

505 PARKVIEW DR
LATHROP MO
64465-9710
US

V. Phone/Fax

Practice location:
  • Phone: 816-589-1355
  • Fax:
Mailing address:
  • Phone: 816-589-1355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2014029027
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: