Basic Information
Provider Information | |||||||||
NPI: | 1083652648 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUTAR | ||||||||
FirstName: | JOY | ||||||||
MiddleName: | JANE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD LMNT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LARSON | ||||||||
OtherFirstName: | JOY | ||||||||
OtherMiddleName: | JANE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 450 E 23RD ST | ||||||||
Address2: |   | ||||||||
City: | FREMONT | ||||||||
State: | NE | ||||||||
PostalCode: | 680252303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4027211610 | ||||||||
FaxNumber: | 4027273433 | ||||||||
Practice Location | |||||||||
Address1: | 450 E 23RD ST | ||||||||
Address2: |   | ||||||||
City: | FREMONT | ||||||||
State: | NE | ||||||||
PostalCode: | 680252303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4027211610 | ||||||||
FaxNumber: | 4027273433 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 472 | NE | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.