Provider Demographics
NPI:1477987576
Name:KIDD, ZACK (RD)
Entity Type:Individual
Prefix:
First Name:ZACK
Middle Name:
Last Name:KIDD
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 1:886 OAK GROVE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:GIBSLAND
Mailing Address - State:LA
Mailing Address - Zip Code:71028-4594
Mailing Address - Country:US
Mailing Address - Phone:940-255-9249
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-990-4084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA886133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA886OtherLOUISIANA DIETETIC ASSOCIATION
LA727068OtherAMERICAN DIETETIC ASSOCIATION