Basic Information
Provider Information | |||||||||
NPI: | 1538490933 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOSSCHER | ||||||||
FirstName: | ALICIA | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPH, RD, CD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEBBINK | ||||||||
OtherFirstName: | ALICIA | ||||||||
OtherMiddleName: | K | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 600 HIGHLAND AVE | ||||||||
Address2: | COMPLIANCE MC 2433 | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537920001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6086620817 | ||||||||
FaxNumber: | 6082034544 | ||||||||
Practice Location | |||||||||
Address1: | 600 HIGHLAND AVE | ||||||||
Address2: | COMPLIANCE MC 2433 | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537920001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6086620817 | ||||||||
FaxNumber: | 6082034544 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2010 | ||||||||
LastUpdateDate: | 02/04/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 946931 |   | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 2172-029 | 01 |   | CERTIFIED DIETITIAN | OTHER |