Provider Demographics
NPI:1003398256
Name:VAN DE WALLE, GAVIN (MS, RD)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:VAN DE WALLE
Suffix:
Gender:M
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 210
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57101-0210
Mailing Address - Country:US
Mailing Address - Phone:605-323-7222
Mailing Address - Fax:
Practice Address - Street 1:1601 E 77TH ST APT 1428
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-3036
Practice Address - Country:US
Practice Address - Phone:605-323-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered