Provider Demographics
NPI:1639792773
Name:BOULTER, ADRIAN SOO (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:SOO
Last Name:BOULTER
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5251 GASMER DR APT 409
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77035-5730
Mailing Address - Country:US
Mailing Address - Phone:903-880-2325
Mailing Address - Fax:
Practice Address - Street 1:5251 GASMER DR APT 409
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77035-5730
Practice Address - Country:US
Practice Address - Phone:903-880-2325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-23
Last Update Date:2020-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86146133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered