Organization
NOURISHED BODY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JILL TERRACCIANO RD (OWNER/ DIETITIAN)
(208) 819-8413
Entity
Organization
Contact information
Practice address
1321 N NORTHWOOD CENTER CT STE B, COEUR D ALENE, ID 83814-4944
(208) 819-8413
Mailing address
1321 N NORTHWOOD CENTER CT STE B, COEUR D ALENE, ID 83814-4944
(208) 819-8413
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1497221220
TIN
WA
Enumeration date
01/22/2024
Last updated
01/22/2024
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