Healthcare Provider Details

I. General information

NPI: 1063479293
Provider Name (Legal Business Name): CYNTHIA ANN RUTKOWSKI MA, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22921 BUCKINGHAM ST
DEARBORN MI
48128-2806
US

IV. Provider business mailing address

22921 BUCKINGHAM ST
DEARBORN MI
48128-2806
US

V. Phone/Fax

Practice location:
  • Phone: 313-278-5217
  • Fax: 313-206-9085
Mailing address:
  • Phone: 313-278-5217
  • Fax: 313-206-9085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberR364117
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: