Provider Demographics
NPI:1689786931
Name:FOX, RITA DOMINGO (MSRDCD)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:DOMINGO
Last Name:FOX
Suffix:
Gender:F
Credentials:MSRDCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 DIXON AVE
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43526-1354
Mailing Address - Country:US
Mailing Address - Phone:419-542-8431
Mailing Address - Fax:
Practice Address - Street 1:2121 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5100
Practice Address - Country:US
Practice Address - Phone:260-436-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000745A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered