MEDICARE: MRS. SUSAN CARROLL KLEMENHAGEN 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

General Provider Information

NPI Number	:	1376634980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN CARROLL KLEMENHAGEN RD LD

Provider Business Mailing Address
First Line	:	2355 OHIO
Second Line	:
City	:	NORTH BEND
State	:	OR
Zip	:	97459
Country	:	US
Telephone Number	:	541-269-8182
Fax Number	:

Provider Business Practice Location Address
First Line	:	1775 THOMPSON RD
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420
Country	:	US
Telephone Number	:	541-269-8182
Fax Number	:	541-266-7829

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

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	07/08/2007

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