Healthcare Provider Details

I. General information

NPI: 1528770641
Provider Name (Legal Business Name): AUGUST NOELANI CORSO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N MICHIGAN ST
SOUTH BEND IN
46601-1087
US

IV. Provider business mailing address

2602 MUIRFIELD DR APT 2A
ELKHART IN
46514-7170
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37003563A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: