Healthcare Provider Details

I. General information

NPI: 1043508674
Provider Name (Legal Business Name): TATE TATRO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 W HIGH ST
JACKSON MI
49203-2986
US

IV. Provider business mailing address

817 W HIGH ST
JACKSON MI
49203-2986
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-9322
  • Fax: 517-787-0836
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number00911572
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: