Provider Demographics
NPI:1932879152
Name:THE MOTHER ROAD DIETITIAN, LLC.
Entity Type:Organization
Organization Name:THE MOTHER ROAD DIETITIAN, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD
Authorized Official - Phone:918-539-0678
Mailing Address - Street 1:8211 EAST REGAL PLACE STE 100
Mailing Address - Street 2:PMB 704
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-7214
Mailing Address - Country:US
Mailing Address - Phone:918-539-0678
Mailing Address - Fax:
Practice Address - Street 1:8211 E REGAL PL STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-7181
Practice Address - Country:US
Practice Address - Phone:918-539-0678
Practice Address - Fax:918-273-6660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-18
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1609546829OtherPERSONAL NPI