Healthcare Provider Details

I. General information

NPI: 1215175609
Provider Name (Legal Business Name): VALERIA GURGEL REZENDE RD,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 01/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 GRANDVILLE AVE SW
GRAND RAPIDS MI
49503-4920
US

IV. Provider business mailing address

5405 EGYPT CREEK BLVD
ADA MI
49301-9278
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-8423
  • Fax:
Mailing address:
  • Phone: 616-682-1525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: