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General NPI Number Information
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NPI Number | 1386140614
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Entity Type | Individual
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Provider Name | ADAM PRUETT RDN
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Gender | Male
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Dates
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Enumeration Date | 04/04/2018
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Last Update Date | 04/04/2018
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Provider Practice Location Address
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Address Line | 5900 BOND AVE
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City | EAST SAINT LOUIS
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State | IL
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Zip | 62207-2326
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Country | US
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Telephone | 618-332-5458
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Fax |
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Provider Business Mailing Address
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Address Line | 5116 EAGLE WING CT
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City | EUREKA
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State | MO
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Zip | 63025-4043
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Country | US
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Telephone | 636-584-9153
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 2008029468
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 164.007263
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License Number State | IL
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