Provider Demographics
NPI:1568651461
Name:SCHROEDER, MAXINE MYRA (RD, LD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:MAXINE
Middle Name:MYRA
Last Name:SCHROEDER
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 E 3500 N
Mailing Address - Street 2:
Mailing Address - City:BUHL
Mailing Address - State:ID
Mailing Address - Zip Code:83316-6214
Mailing Address - Country:US
Mailing Address - Phone:208-543-6579
Mailing Address - Fax:
Practice Address - Street 1:388 MARTIN ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4544
Practice Address - Country:US
Practice Address - Phone:208-734-0451
Practice Address - Fax:208-734-0452
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-219133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806421400Medicaid
ID1940125Medicare PIN