Provider Demographics
NPI:1033855028
Name:KANDIS GROSE MS RD LN LLC
Entity Type:Organization
Organization Name:KANDIS GROSE MS RD LN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KANDIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LN
Authorized Official - Phone:406-839-3851
Mailing Address - Street 1:PO BOX 44
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MT
Mailing Address - Zip Code:59870-0044
Mailing Address - Country:US
Mailing Address - Phone:406-839-3851
Mailing Address - Fax:
Practice Address - Street 1:649 MIDDLE BURNT FORK RD
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MT
Practice Address - Zip Code:59870
Practice Address - Country:US
Practice Address - Phone:406-839-3851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty