Healthcare Provider Details

I. General information

NPI: 1104578368
Provider Name (Legal Business Name): MKL CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 HOGBACK RD STE 6F
ANN ARBOR MI
48105-8800
US

IV. Provider business mailing address

2010 HOGBACK RD STE 6F
ANN ARBOR MI
48105-8800
US

V. Phone/Fax

Practice location:
  • Phone: 734-887-6027
  • Fax: 248-742-8088
Mailing address:
  • Phone: 734-887-6027
  • Fax: 248-742-8088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MARIAH LEWIS
Title or Position: PRESIDENT/OWNER
Credential: RDN
Phone: 734-887-6027