Basic Information
| Provider Information | |||||||||
| NPI: | 1720545627 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRIDER | ||||||||
| FirstName: | ROSE | ||||||||
| MiddleName: | ALICIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BETZLER | ||||||||
| OtherFirstName: | ROSE | ||||||||
| OtherMiddleName: | ALICIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5803 BRYANT AVE S | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554192101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6129878776 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3850 PARK NICOLLET BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554162527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529933400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2019 | ||||||||
| LastUpdateDate: | 02/27/2019 | ||||||||
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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 | 3712 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.