Provider Demographics
NPI:1447517933
Name:BLUME, KEVIN (RD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BLUME
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 BAKER ST APT 4
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3276
Mailing Address - Country:US
Mailing Address - Phone:208-890-5241
Mailing Address - Fax:
Practice Address - Street 1:1225 N GRAND AVE # B
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-3426
Practice Address - Country:US
Practice Address - Phone:208-890-5241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI 60270930133V00000X
IDD-683133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered