Healthcare Provider Details

I. General information

NPI: 1609176882
Provider Name (Legal Business Name): CAROLE GRANT RD,LD,CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2010
Last Update Date: 03/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WEST HOSPITAL DRIVE
WHITERIVER AZ
85941
US

IV. Provider business mailing address

1081 E CEDAR RIDGE RUN
SHOW LOW AZ
85901-7308
US

V. Phone/Fax

Practice location:
  • Phone: 928-338-3647
  • Fax:
Mailing address:
  • Phone: 928-338-3647
  • Fax: 928-338-3522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberLD003592
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: