=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770736522
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY MARIE KUBAL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2008
-----------------------------------------------------
Last Update Date | 02/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2450 RISNER DRIVE ELLSWORTH AIR FORCE BASE HEALTH AND WELLNESS CENTER
-----------------------------------------------------
City | ELLSWORTH AFB
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-385-2349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4521 HOMESTEAD ST #303
-----------------------------------------------------
City | RAPID CITY
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57703-0223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-420-1642
-----------------------------------------------------
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 | 00915063
-----------------------------------------------------
License Number State |
-----------------------------------------------------