Healthcare Provider Details

I. General information

NPI: 1205454766
Provider Name (Legal Business Name): DISEASE MANAGEMENT AND PREVENTION DIETITIANS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 19TH AVE N STE 178
FARGO ND
58102-5906
US

IV. Provider business mailing address

1100 19TH AVE N STE 178
FARGO ND
58102-5906
US

V. Phone/Fax

Practice location:
  • Phone: 701-532-1683
  • Fax:
Mailing address:
  • Phone: 701-532-1683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: CARRIE MCLEOD
Title or Position: PRESIDENT
Credential: LRD, RDN,CDE
Phone: 701-532-1683