MEDICARE: SUE DYKE 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	723957-RD	MN

General Provider Information

NPI Number	:	1245300748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUE DYKE RD, LD

Provider Business Mailing Address
First Line	:	1755 SOUTHCROSS DR W
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55306-7012
Country	:	US
Telephone Number	:	952-898-5020
Fax Number	:	952-898-5858

Provider Business Practice Location Address
First Line	:	1755 SOUTHCROSS DR W
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55306-7012
Country	:	US
Telephone Number	:	952-898-5020
Fax Number	:	952-898-5858

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

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	02/06/2008

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