Provider Demographics
NPI:1598085839
Name:PINE, BERNICE RUTH (RD)
Entity Type:Individual
Prefix:MISS
First Name:BERNICE
Middle Name:RUTH
Last Name:PINE
Suffix:
Gender:F
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:P.O. BOX 383
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13053
Mailing Address - Country:US
Mailing Address - Phone:607-753-5061
Mailing Address - Fax:607-756-3478
Practice Address - Street 1:1 BELLA VISTA DRIVE
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-375-6330
Practice Address - Fax:607-375-6301
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
305324133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered