Basic Information
Provider Information | |||||||||
NPI: | 1861538514 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TOWN | ||||||||
FirstName: | DEVIN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, RD, CD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HUCK | ||||||||
OtherFirstName: | DEVIN | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS,RD,CD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 660 S COOLIDGE ST | ||||||||
Address2: |   | ||||||||
City: | MOSES LAKE | ||||||||
State: | WA | ||||||||
PostalCode: | 988371872 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5097939715 | ||||||||
FaxNumber: | 5097643244 | ||||||||
Practice Location | |||||||||
Address1: | 1550 S PIONEER WAY | ||||||||
Address2: |   | ||||||||
City: | MOSES LAKE | ||||||||
State: | WA | ||||||||
PostalCode: | 988374613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5097939780 | ||||||||
FaxNumber: | 5097643244 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2007 | ||||||||
LastUpdateDate: | 03/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 954800 |   | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 133V00000X | DI00001757 | WA | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 8450538 | 05 | WA |   | MEDICAID | 2161329 | 05 | WA |   | MEDICAID |