=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285143651
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RURAL ROOTS NUTRITION PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2017
-----------------------------------------------------
Last Update Date | 09/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1672 POMPEY CENTER RD
-----------------------------------------------------
City | FABIUS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13063-8703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-683-4263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1672 POMPEY CENTER RD
-----------------------------------------------------
City | FABIUS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13063-8703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR/OWNER
-----------------------------------------------------
Name | CAROLYN H ALLEN
-----------------------------------------------------
Credential | MS, RD, CDN
-----------------------------------------------------
Telephone | 315-683-4263
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 5036296
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------