Provider Demographics
NPI:1821372376
Name:PACKARD, RICHARD EDWARD JR (RDN, LDN, MBA, CDCES)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:EDWARD
Last Name:PACKARD
Suffix:JR
Gender:M
Credentials:RDN, LDN, MBA, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-1716
Mailing Address - Country:US
Mailing Address - Phone:607-317-7177
Mailing Address - Fax:607-302-4106
Practice Address - Street 1:200 MEADOW DR
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-1716
Practice Address - Country:US
Practice Address - Phone:607-317-7177
Practice Address - Fax:607-302-4106
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV598133V00000X
NY010583133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered