Provider Demographics
NPI:1134487648
Name:HARRIS, LADD (RD)
Entity Type:Individual
Prefix:
First Name:LADD
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:486 E 9270 S
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-6240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1020 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4838
Practice Address - Country:US
Practice Address - Phone:850-916-8650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003966133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered