Healthcare Provider Details

I. General information

NPI: 1285029017
Provider Name (Legal Business Name): YOUR SPECIALIZED DIETITIAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 W MAIN ST
WHITESBORO TX
76273-1641
US

IV. Provider business mailing address

408 WEST MAIN ST
WHITESBORO TX
76273
US

V. Phone/Fax

Practice location:
  • Phone: 903-816-3657
  • Fax: 817-977-7406
Mailing address:
  • Phone: 903-816-3657
  • Fax: 817-977-7406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT80568
License Number StateTX

VIII. Authorized Official

Name: MR. KYLE FIELDING ROSE
Title or Position: OWNER
Credential: RD
Phone: 903-816-3657