Healthcare Provider Details

I. General information

NPI: 1104924406
Provider Name (Legal Business Name): VIRGINIA RUTH TERRY R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 W HARVARD AVE STE 427
ROSEBURG OR
97471-8712
US

IV. Provider business mailing address

1866 NE KLAMATH AVE
ROSEBURG OR
97470-3554
US

V. Phone/Fax

Practice location:
  • Phone: 541-784-5966
  • Fax:
Mailing address:
  • Phone: 541-784-5966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number811605
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: