Basic Information
| Provider Information | |||||||||
| NPI: | 1114126729 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BECKIUS | ||||||||
| FirstName: | HOLLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 ELM ST N | ||||||||
| Address2: | 120 | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581022417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012393700 | ||||||||
| FaxNumber: | 7012372485 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 ELM ST N | ||||||||
| Address2: | 120 | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581022417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012393700 | ||||||||
| FaxNumber: | 7012372485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2007 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 885625 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 2594 | 01 | MN | MEDICARE PIN, MEDICARE UP | OTHER |