Healthcare Provider Details

I. General information

NPI: 1588966477
Provider Name (Legal Business Name): ELISABETH FABER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2010
Last Update Date: 11/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

4228 PEAK LN NE
GRAND RAPIDS MI
49525-9402
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-9488
  • Fax:
Mailing address:
  • Phone: 616-447-8456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number919238
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: