Provider Demographics
NPI:1578134243
Name:EDMISTON, HOWARD WILLIAM IV (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:WILLIAM
Last Name:EDMISTON
Suffix:IV
Gender:M
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:EDMISTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:117 ALAMO DR
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-7253
Mailing Address - Country:US
Mailing Address - Phone:910-476-1822
Mailing Address - Fax:
Practice Address - Street 1:117 ALAMO DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-7253
Practice Address - Country:US
Practice Address - Phone:910-476-1822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-1166133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered