Healthcare Provider Details

I. General information

NPI: 1639522436
Provider Name (Legal Business Name): ERIN KUKURA MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 11/08/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61133 HALLEY ST
BEND OR
97702
US

IV. Provider business mailing address

61133 HALLEY ST
BEND OR
97702-2879
US

V. Phone/Fax

Practice location:
  • Phone: 458-202-9495
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10224645
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: