Healthcare Provider Details

I. General information

NPI: 1891923660
Provider Name (Legal Business Name): ELISE MICHELLE KEATON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E WARWICK DR
ALMA MI
48801-1014
US

IV. Provider business mailing address

PO BOX 608
ALMA MI
48801-0608
US

V. Phone/Fax

Practice location:
  • Phone: 989-466-3330
  • Fax: 989-463-2540
Mailing address:
  • Phone: 989-466-3330
  • Fax: 989-463-2540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: