Healthcare Provider Details

I. General information

NPI: 1609975721
Provider Name (Legal Business Name): MARGARET JANE MALL RD LN BC-ADM CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 BIA ROUTE 4
FORT THOMPSON SD
57339-0200
US

IV. Provider business mailing address

PO BOX 200 1323 BIA ROUTE 4
FORT THOMPSON SD
57339-0200
US

V. Phone/Fax

Practice location:
  • Phone: 604-245-1534
  • Fax:
Mailing address:
  • Phone: 604-245-1534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number425
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: