Healthcare Provider Details

I. General information

NPI: 1740486778
Provider Name (Legal Business Name): LISA MARIE BECKER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 N PARK ST
NORTHWOOD ND
58267-4103
US

IV. Provider business mailing address

2101 94TH AVE NE
MCHENRY ND
58464-9268
US

V. Phone/Fax

Practice location:
  • Phone: 701-587-6000
  • Fax: 701-587-6009
Mailing address:
  • Phone: 701-262-4925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number117
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: