Healthcare Provider Details

I. General information

NPI: 1508262494
Provider Name (Legal Business Name): BRENDA PENDARVIS R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12505 BARNES TER
MOORE OK
73170-3408
US

IV. Provider business mailing address

12505 BARNES TER
MOORE OK
73170-3408
US

V. Phone/Fax

Practice location:
  • Phone: 405-380-3031
  • Fax:
Mailing address:
  • Phone: 405-380-3031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD1295
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: