MEDICARE: MRS. BETHANY JOY MOTLEY RD

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	4454	MN

General Provider Information

NPI Number	:	1255083671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BETHANY JOY MOTLEY RD

Provider Business Mailing Address
First Line	:	5625 VINE HILL RD
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-5038
Country	:	US
Telephone Number	:	218-213-6472
Fax Number	:

Provider Business Practice Location Address
First Line	:	5625 VINE HILL RD
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-5038
Country	:	US
Telephone Number	:	218-213-6472
Fax Number	:

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

Provider Enumeration Date	:	01/26/2022
Last Update Date	:	01/26/2022

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