MEDICARE: KYLE LOUIS STANSBERRY RDN

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

General Provider Information

NPI Number	:	1538624325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE LOUIS STANSBERRY RDN

Provider Business Mailing Address
First Line	:	8080 UPHAM DR
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-9403
Country	:	US
Telephone Number	:	989-506-1179
Fax Number	:

Provider Business Practice Location Address
First Line	:	8080 UPHAM DR
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-9403
Country	:	US
Telephone Number	:	989-506-1179
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2019
Last Update Date	:	02/05/2019

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