Healthcare Provider Details

I. General information

NPI: 1306170030
Provider Name (Legal Business Name): EILEEN FAY LARYEA RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EILEEN FAY BROWN RD

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 E JOLLY RD STE 216
LANSING MI
48910-6825
US

IV. Provider business mailing address

737 BANCROFT CT
LANSING MI
48915-1931
US

V. Phone/Fax

Practice location:
  • Phone: 517-346-8200
  • Fax:
Mailing address:
  • Phone: 517-488-3702
  • 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: