Provider Demographics
NPI:1669211694
Name:EGDORF, REBECCA (RDN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:EGDORF
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14475 US HIGHWAY 160 UNIT A
Mailing Address - Street 2:
Mailing Address - City:DEL NORTE
Mailing Address - State:CO
Mailing Address - Zip Code:81132-9713
Mailing Address - Country:US
Mailing Address - Phone:937-726-7253
Mailing Address - Fax:
Practice Address - Street 1:14475 US HIGHWAY 160 UNIT A
Practice Address - Street 2:
Practice Address - City:DEL NORTE
Practice Address - State:CO
Practice Address - Zip Code:81132-9713
Practice Address - Country:US
Practice Address - Phone:937-726-7253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82416133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered