Provider Demographics
NPI:1639786742
Name:SCARDIGLI, SAM LUCAS (MS, RD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:LUCAS
Last Name:SCARDIGLI
Suffix:
Gender:M
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 177TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-1539
Mailing Address - Country:US
Mailing Address - Phone:763-568-8899
Mailing Address - Fax:
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2736
Practice Address - Country:US
Practice Address - Phone:320-240-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered