Provider Demographics
NPI:1720545627
Name:CRIDER, ROSE ALICIA (RD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:ALICIA
Last Name:CRIDER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:ALICIA
Other - Last Name:BETZLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:5803 BRYANT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-2101
Mailing Address - Country:US
Mailing Address - Phone:612-987-8776
Mailing Address - Fax:
Practice Address - Street 1:3850 PARK NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3712133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered