Healthcare Provider Details

I. General information

NPI: 1922702638
Provider Name (Legal Business Name): BRENT TANNIN TABATA MS, RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 LAFAYETTE AVE SE STE 400
GRAND RAPIDS MI
49503-4677
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-486-6870
  • Fax: 616-454-6898
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number973751
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: