Healthcare Provider Details

I. General information

NPI: 1710308804
Provider Name (Legal Business Name): BETHANY ERICSON RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2013
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 SW 9TH ST
ONTARIO OR
97914-2639
US

IV. Provider business mailing address

351 SW 9TH ST
ONTARIO OR
97914-2639
US

V. Phone/Fax

Practice location:
  • Phone: 208-899-7933
  • Fax:
Mailing address:
  • Phone: 208-899-7933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-778
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDD10158487
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: