Healthcare Provider Details

I. General information

NPI: 1932474566
Provider Name (Legal Business Name): KRISTINE L GODBOLD R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 KERCHEVAL ST
DETROIT MI
48214-2439
US

IV. Provider business mailing address

13901 E JEFFERSON AVE
DETROIT MI
48215-2720
US

V. Phone/Fax

Practice location:
  • Phone: 313-921-5500
  • Fax:
Mailing address:
  • Phone: 313-921-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number883716
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: