Healthcare Provider Details

I. General information

NPI: 1811324197
Provider Name (Legal Business Name): SENIOR NUTRITION SERVICES REGION IV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 COLFAX AVE
BENTON HARBOR MI
49022-6709
US

IV. Provider business mailing address

1708 COLFAX AVE
BENTON HARBOR MI
49022-6709
US

V. Phone/Fax

Practice location:
  • Phone: 269-925-0137
  • Fax: 269-925-0557
Mailing address:
  • Phone: 269-925-0137
  • Fax: 269-925-0557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335G00000X
TaxonomyMedical Foods Supplier
License Number
License Number State

VIII. Authorized Official

Name: MS. LINDA K STROHL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 269-925-0137