MEDICARE: KIMBERLY O'BRIEN RD, LD

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
1	133V00000X	Registered Dietitian	812818-RD	MN

General Provider Information

NPI Number	:	1104996602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY O'BRIEN RD, LD

Provider Business Mailing Address
First Line	:	2356 APACHE CT
Second Line	:
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55120-1684
Country	:	US
Telephone Number	:	651-405-8712
Fax Number	:

Provider Business Practice Location Address
First Line	:	2356 APACHE CT
Second Line	:
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55120-1684
Country	:	US
Telephone Number	:	651-405-8712
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	06/19/2014

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