1164880746 NPI number — MRS. KANDI DENISE DAWSON RD, CD, CDE

Table of content: MRS. KANDI DENISE DAWSON RD, CD, CDE (NPI 1164880746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164880746 NPI number — MRS. KANDI DENISE DAWSON RD, CD, CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAWSON
Provider First Name:
KANDI
Provider Middle Name:
DENISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, CD, CDE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BACHMAN
Provider Other First Name:
KANDI
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164880746
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2520 E. DUPONT RD
Provider Second Line Business Mailing Address:
NUTRITION SERVICES
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-416-3263
Provider Business Mailing Address Fax Number:
260-416-3304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2520 E. DUPONT RD
Provider Second Line Business Practice Location Address:
NUTRITION SERVICES
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-416-3263
Provider Business Practice Location Address Fax Number:
260-416-3304
Provider Enumeration Date:
02/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  37000663A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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