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NPI Code Detail

MEDICARE: ABIGAIL RENN RD LN

MEDICARE: ABIGAIL RENN RD LN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian0695SD

General Provider Information

NPI Number : 1003428053
Entity Type Code : Individual
Provider Name (Legal Business Name) : ABIGAIL RENN RD LN
Provider Business Mailing Address
First Line : 353 FAIRMONT BLVD
Second Line :
City : RAPID CITY
State : SD
Zip : 57701-7375
Country : US
Telephone Number : 605-755-4755
Fax Number :
Provider Business Practice Location Address
First Line : 353 FAIRMONT BLVD
Second Line :
City : RAPID CITY
State : SD
Zip : 57701-7375
Country : US
Telephone Number : 605-755-4755
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/20/2020
Last Update Date : 08/20/2020

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Directions to “ ABIGAIL RENN RD LN” Practice Location

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