MEDICARE: MRS. LISA ALICE ROSS 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	1968	MN

General Provider Information

NPI Number	:	1205925252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA ALICE ROSS RD, LD

Provider Business Mailing Address
First Line	:	1620 W LAKE ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2549
Country	:	US
Telephone Number	:	612-822-5973
Fax Number	:	612-822-1132

Provider Business Practice Location Address
First Line	:	1620 W LAKE ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2549
Country	:	US
Telephone Number	:	612-822-5973
Fax Number	:	612-822-1132

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/08/2007

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