Healthcare Provider Details

I. General information

NPI: 1275920290
Provider Name (Legal Business Name): DEBORAH GRANDYS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 BROADWAY SUITE D1
MERRILLVILLE IN
46410-8602
US

IV. Provider business mailing address

8300 BROADWAY SUITE D1
MERRILLVILLE IN
46410-8602
US

V. Phone/Fax

Practice location:
  • Phone: 219-750-9497
  • Fax: 219-359-3181
Mailing address:
  • Phone: 219-750-9497
  • Fax: 219-359-3181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37001319A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: