MEDICARE: SPROUT HEALTHY HABITS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	727212	MI

General Provider Information

NPI Number	:	1235683426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPROUT HEALTHY HABITS, LLC

Provider Business Mailing Address
First Line	:	984 SPRINGFIELD CT
Second Line	:
City	:	NORTHVILLE
State	:	MI
Zip	:	48167-1030
Country	:	US
Telephone Number	:	248-821-9388
Fax Number	:

Provider Business Practice Location Address
First Line	:	984 SPRINGFIELD CT
Second Line	:
City	:	NORTHVILLE
State	:	MI
Zip	:	48167-1030
Country	:	US
Telephone Number	:	248-821-9388
Fax Number	:

Authorized Official
Title or Position	:	OWNER-OPERATOR
Name	:	MRS. NICOLE ANN LEROY
Credential	:	RD
Telephone Number	:	248-821-9388

Provider Enumeration Date	:	08/05/2016
Last Update Date	:	08/05/2016

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