Healthcare Provider Details

I. General information

NPI: 1497127252
Provider Name (Legal Business Name): TIFFANY AUTUMN SWARTZENTRUBER RD, CSO, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

IV. Provider business mailing address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

V. Phone/Fax

Practice location:
  • Phone: 574-364-2455
  • Fax: 574-364-2544
Mailing address:
  • Phone: 574-364-2455
  • Fax: 574-364-2544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37001894A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: