Provider Demographics
NPI:1487131991
Name:SALEM DIETETICS, LLC
Entity type:Organization
Organization Name:SALEM DIETETICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SALEM
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, CDE
Authorized Official - Phone:917-330-8441
Mailing Address - Street 1:9325 UPLAND LN N STE 320
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9325 UPLAND LN N STE 320
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4451
Practice Address - Country:US
Practice Address - Phone:917-330-8441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-26
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========Medicaid