MEDICARE: MARGARET JANE MALL RD LN BC-ADM CDE

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	133NN1002X	Nutrition Education Nutritionist	425	MT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	HSZ196	OTHER	NM	MEDICARE PART B

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609975721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARGARET JANE MALL RD LN BC-ADM CDE

Provider Business Mailing Address
First Line	:	PO BOX 200
Second Line	:	1323 BIA ROUTE 4
City	:	FORT THOMPSON
State	:	SD
Zip	:	57339-0200
Country	:	US
Telephone Number	:	604-245-1534
Fax Number	:

Provider Business Practice Location Address
First Line	:	1323 BIA ROUTE 4
Second Line	:
City	:	FORT THOMPSON
State	:	SD
Zip	:	57339-0200
Country	:	US
Telephone Number	:	604-245-1534
Fax Number	:

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

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	06/05/2015

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