Provider Demographics
NPI:1578161238
Name:FRIDERES, KAIMEN L
Entity Type:Individual
Prefix:
First Name:KAIMEN
Middle Name:L
Last Name:FRIDERES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 734839
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-4839
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:2019 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4921
Practice Address - Country:US
Practice Address - Phone:812-949-5700
Practice Address - Fax:812-949-5791
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37003240A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered