Healthcare Provider Details

I. General information

NPI: 1356656581
Provider Name (Legal Business Name): WILLIAM SOLOMON WONNENBERG LMNT, RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 02/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SOLDIER CREEK ROAD
ROSEBUD SD
57570-0400
US

IV. Provider business mailing address

PO BOX 400
ROSEBUD SD
57570-0400
US

V. Phone/Fax

Practice location:
  • Phone: 605-747-2231
  • Fax: 605-747-2216
Mailing address:
  • Phone: 605-747-2231
  • Fax: 605-747-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number966
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number966
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: