Healthcare Provider Details

I. General information

NPI: 1982818449
Provider Name (Legal Business Name): CATHY B IMDIEKE LRD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 NE 1ST ST.
LINTON ND
58552-0527
US

IV. Provider business mailing address

519 NE 1ST ST.
LINTON ND
58552-0527
US

V. Phone/Fax

Practice location:
  • Phone: 701-254-4104
  • Fax:
Mailing address:
  • Phone: 701-254-4104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number91
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: