MEDICARE: REIDENBACH NUTRITION, LLC

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	37000578A	IN

General Provider Information

NPI Number	:	1922377423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REIDENBACH NUTRITION, LLC

Provider Business Mailing Address
First Line	:	6522 CONSTITUTION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1550
Country	:	US
Telephone Number	:	260-433-3877
Fax Number	:	260-755-5731

Provider Business Practice Location Address
First Line	:	6522 CONSTITUTION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1550
Country	:	US
Telephone Number	:	260-433-3877
Fax Number	:	260-755-5731

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANN REIDENBACH
Credential	:	RD, CD
Telephone Number	:	260-433-3877

Provider Enumeration Date	:	12/29/2011
Last Update Date	:	12/29/2011

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