Healthcare Provider Details

I. General information

NPI: 1396167573
Provider Name (Legal Business Name): SCOTT KENNETH HAESE MPH, RD, LN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1984 CAMEO DR
ALAMOGORDO NM
88310-8508
US

IV. Provider business mailing address

1984 CAMEO DR
ALAMOGORDO NM
88310-8508
US

V. Phone/Fax

Practice location:
  • Phone: 575-491-2572
  • Fax: 320-213-9346
Mailing address:
  • Phone: 575-491-2572
  • Fax: 320-213-9346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number328
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number717594
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: