Healthcare Provider Details

I. General information

NPI: 1053645317
Provider Name (Legal Business Name): BROOKE LEIGH FREDRICKSON LRD, CSG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 09/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 ROBERTS AVE NE
COOPERSTOWN ND
58425-7101
US

IV. Provider business mailing address

80 COUNTY ROAD 19
COOPERSTOWN ND
58425-9168
US

V. Phone/Fax

Practice location:
  • Phone: 701-797-2221
  • Fax:
Mailing address:
  • Phone: 701-361-7154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number669
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: