=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730180142
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY GRACE ALDRICH R.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6717 E 2ND ST STE. D
-----------------------------------------------------
City | PRESCOTT VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86314-2659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-771-3560
-----------------------------------------------------
Fax | 928-771-3542
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6717 E 2ND ST STE. D
-----------------------------------------------------
City | PRESCOTT VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86314-2659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-771-3560
-----------------------------------------------------
Fax | 928-771-3542
-----------------------------------------------------
=====================================================
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 | 853106
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------