Provider Demographics
NPI:1427161199
Name:BOLZER, ROSLYN RUTH (RD, LN)
Entity type:Individual
Prefix:MRS
First Name:ROSLYN
Middle Name:RUTH
Last Name:BOLZER
Suffix:
Gender:F
Credentials: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:PO BOX 540
Mailing Address - Street 2:1000 HEALTH CENTER ROAD
Mailing Address - City:KYLE
Mailing Address - State:SD
Mailing Address - Zip Code:57752-0540
Mailing Address - Country:US
Mailing Address - Phone:605-455-8239
Mailing Address - Fax:605-455-1584
Practice Address - Street 1:1000 HEALTH CENTER ROAD
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:SD
Practice Address - Zip Code:57752-0540
Practice Address - Country:US
Practice Address - Phone:605-455-8823
Practice Address - Fax:605-455-1584
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0150133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDHSZ146/8HBB51Medicare UPIN
SDHSZ146/8HBB51Medicare ID - Type Unspecified