MEDICARE: MRS. KIMBERLY RAE LARSON MS, RD, LN

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	500	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	500	OTHER	MT	LICENSED NUTRITIONIST

General Provider Information

NPI Number	:	1851465694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY RAE LARSON MS, RD, LN

Provider Business Mailing Address
First Line	:	120 N 19TH AVE STE D
Second Line	:
City	:	BOZEMAN
State	:	MT
Zip	:	59718-3920
Country	:	US
Telephone Number	:	406-522-4601
Fax Number	:	406-522-4656

Provider Business Practice Location Address
First Line	:	120 N 19TH AVE STE D
Second Line	:
City	:	BOZEMAN
State	:	MT
Zip	:	59718-3920
Country	:	US
Telephone Number	:	406-522-4601
Fax Number	:	406-522-4656

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

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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