MEDICARE: MS. BETHANY MICHELLE ROSE RD, CSR, 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	264496	KY
2	133VN1005X	Renal Nutrition Registered Dietitian	LD.10377	OH

General Provider Information

NPI Number	:	1285241166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BETHANY MICHELLE ROSE RD, CSR, LD

Provider Business Mailing Address
First Line	:	2529 VALAIS CT
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45458-5408
Country	:	US
Telephone Number	:	270-723-2930
Fax Number	:

Provider Business Practice Location Address
First Line	:	5721 BIGGER RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45440-2752
Country	:	US
Telephone Number	:	270-723-2930
Fax Number	:

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

Provider Enumeration Date	:	09/25/2020
Last Update Date	:	03/07/2025

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