MEDICARE: JILL MARIA BREYEN 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	2050	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2050	OTHER	MN	DIETETICS

General Provider Information

NPI Number	:	1952475063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL MARIA BREYEN RD,LD

Provider Business Mailing Address
First Line	:	PO BOX 497
Second Line	:
City	:	REDLAKE
State	:	MN
Zip	:	56671-0497
Country	:	US
Telephone Number	:	218-679-3912
Fax Number	:	218-679-0181

Provider Business Practice Location Address
First Line	:	HWY 1
Second Line	:
City	:	REDLAKE
State	:	MN
Zip	:	56671-0497
Country	:	US
Telephone Number	:	218-679-3912
Fax Number	:	218-679-0181

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

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	01/22/2008

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Directions to “ JILL MARIA BREYEN RD,LD” Practice Location

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