=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588066336
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN DRAIN RD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2014
-----------------------------------------------------
Last Update Date | 03/26/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1233 34TH ST NW
-----------------------------------------------------
City | BEMIDJI
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56601-5112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-333-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5074
-----------------------------------------------------
City | SIOUX FALLS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57117-5074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | D-797
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 5829
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------