Healthcare Provider Details

I. General information

NPI: 1053853168
Provider Name (Legal Business Name): GARDENS AT ROUNDTABLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 SOUTH ST
LAFAYETTE IN
47901-1416
US

IV. Provider business mailing address

904 SOUTH ST
LAFAYETTE IN
47901-1416
US

V. Phone/Fax

Practice location:
  • Phone: 765-630-7222
  • Fax: 765-807-3210
Mailing address:
  • Phone: 765-630-7222
  • Fax: 765-807-3210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: RENEE MICHELLE TILT
Title or Position: OWNER & REGISTERED DIETITIAN
Credential: RDN, CSP
Phone: 765-630-7222