Healthcare Provider Details

I. General information

NPI: 1831126366
Provider Name (Legal Business Name): RONALD RAYMOND SANDRETH JR. RD,LD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LOUIS A. JOHNSON VAMC 1 MEDICAL CENTER DRIVE
CLARKSBURG WV
26301
US

IV. Provider business mailing address

1 MEDICAL CENTER DR LOUIS A JOHNSON VAMC
CLARKSBURG WV
26301
US

V. Phone/Fax

Practice location:
  • Phone: 304-626-7730
  • Fax:
Mailing address:
  • Phone: 304-626-7730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number186
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: