Basic Information
| Provider Information | |||||||||
| NPI: | 1275781445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALLEMEYN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3450 | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577093450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057191000 | ||||||||
| FaxNumber: | 6057197680 | ||||||||
| Practice Location | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057191000 | ||||||||
| FaxNumber: | 6057197680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2008 | ||||||||
| LastUpdateDate: | 09/04/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1013864 | SD | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1013864 | 01 | SD | LICENSE | OTHER |