Provider Demographics
NPI:1396167573
Name:HAESE, SCOTT KENNETH (MPH, RD, LN)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:KENNETH
Last Name:HAESE
Suffix:
Gender:M
Credentials:MPH, RD, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1984 CAMEO DR
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8508
Mailing Address - Country:US
Mailing Address - Phone:575-491-2572
Mailing Address - Fax:320-213-9346
Practice Address - Street 1:1984 CAMEO DR
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8508
Practice Address - Country:US
Practice Address - Phone:575-491-2572
Practice Address - Fax:320-213-9346
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM328133N00000X
NM717594133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist