MEDICARE: LARISSA ROSE EADEN 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		CO

General Provider Information

NPI Number	:	1528848660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARISSA ROSE EADEN RD

Provider Business Mailing Address
First Line	:	2802 BRIGHTWATER CT
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-6716
Country	:	US
Telephone Number	:	941-330-4884
Fax Number	:

Provider Business Practice Location Address
First Line	:	2802 BRIGHTWATER CT
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-6716
Country	:	US
Telephone Number	:	941-330-4884
Fax Number	:

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

Provider Enumeration Date	:	10/05/2023
Last Update Date	:	10/05/2023

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