Healthcare Provider Details

I. General information

NPI: 1124228275
Provider Name (Legal Business Name): PRUDENT-LIFESTYLES NUTRITION SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17570 SAN ROSA BLVD
LATHRUP VILLAGE MI
48076-2715
US

IV. Provider business mailing address

17570 SAN ROSA BLVD
LATHRUP VILLAGE MI
48076-2715
US

V. Phone/Fax

Practice location:
  • Phone: 248-866-4967
  • Fax: 248-559-5081
Mailing address:
  • Phone: 248-866-4967
  • Fax: 248-559-5081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MS. TONJA MARIA STALLINGS
Title or Position: DIETITIAN
Credential: R.D.
Phone: 248-866-4967