Healthcare Provider Details

I. General information

NPI: 1558448035
Provider Name (Legal Business Name): GWEN MARIE EHLERS RD. CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E LASALLE AVE
SOUTH BEND IN
46617-2814
US

IV. Provider business mailing address

13898 LAYTON RD
MISHAWAKA IN
46544-9498
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-7514
  • Fax:
Mailing address:
  • Phone: 574-633-4748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37001241A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: