Provider Demographics
NPI:1790239630
Name:KORDICK, LINDSAY
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:
Last Name:KORDICK
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 1:935 HIGHLAND BLVD
Mailing Address - Street 2:SUITE 2180
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6904
Mailing Address - Country:US
Mailing Address - Phone:406-414-5331
Mailing Address - Fax:
Practice Address - Street 1:935 HIGHLAND BLVD
Practice Address - Street 2:SUITE 2180
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6904
Practice Address - Country:US
Practice Address - Phone:406-414-5331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-NUTR-LIC-574133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered