Provider Demographics
NPI:1063979961
Name:PRAIRIE VIEW CREATIONS LLC
Entity type:Organization
Organization Name:PRAIRIE VIEW CREATIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HETHERWICK
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD
Authorized Official - Phone:928-772-8652
Mailing Address - Street 1:PO BOX 10214
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0214
Mailing Address - Country:US
Mailing Address - Phone:928-772-8652
Mailing Address - Fax:928-772-8078
Practice Address - Street 1:8508 N PRAIRIE VW
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86315-9089
Practice Address - Country:US
Practice Address - Phone:928-772-8652
Practice Address - Fax:928-772-8078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-27
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Multi-Specialty
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, RenalGroup - Multi-Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ488506Medicaid