Basic Information
Provider Information | |||||||||
NPI: | 1821372376 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PACKARD | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | RDN, LDN, MBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILLIAMS | ||||||||
OtherFirstName: | RICHARD | ||||||||
OtherMiddleName: | EDWARD | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RD, LDN, MBA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 571 SAINT JOSEPHS BLVD FL 2 | ||||||||
Address2: |   | ||||||||
City: | ELMIRA | ||||||||
State: | NY | ||||||||
PostalCode: | 149013230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6072712050 | ||||||||
FaxNumber: | 6078731244 | ||||||||
Practice Location | |||||||||
Address1: | 600 ROE AVE # 1G | ||||||||
Address2: |   | ||||||||
City: | ELMIRA | ||||||||
State: | NY | ||||||||
PostalCode: | 149051676 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077952820 | ||||||||
FaxNumber: | 6077952821 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2011 | ||||||||
LastUpdateDate: | 09/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 598 | WV | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 133V00000X | 010583 | NY | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.