Provider Demographics
NPI:1881463370
Name:GROATHOUSE, DEREK (RD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:GROATHOUSE
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 S DUFF AVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-8504
Mailing Address - Country:US
Mailing Address - Phone:515-480-8761
Mailing Address - Fax:
Practice Address - Street 1:3801 S JAMES ST STE 400
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-5167
Practice Address - Country:US
Practice Address - Phone:515-695-3767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA121584133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered