Healthcare Provider Details

I. General information

NPI: 1093836025
Provider Name (Legal Business Name): MARY BETH LAROCK R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DELAFIELD ST STE 212
WAUKESHA WI
53188-3403
US

IV. Provider business mailing address

2301 SUN VALLEY DR STE 200
DELAFIELD WI
53018-2318
US

V. Phone/Fax

Practice location:
  • Phone: 262-524-1024
  • Fax: 262-524-8767
Mailing address:
  • Phone: 262-646-6426
  • Fax: 262-646-2498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberR528717
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: