Healthcare Provider Details

I. General information

NPI: 1659139129
Provider Name (Legal Business Name): THE FARM FRESH RD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W2403 FOX COULEE RD
NELSON WI
54756-8000
US

IV. Provider business mailing address

W2403 FOX COULEE RD
NELSON WI
54756-8000
US

V. Phone/Fax

Practice location:
  • Phone: 715-495-2398
  • Fax:
Mailing address:
  • Phone: 715-495-2398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ADRIAN A LEQUE
Title or Position: REGISTERED DIETITIAN
Credential: MS, RD, LD, CD, FAND
Phone: 715-495-2398