Healthcare Provider Details

I. General information

NPI: 1548867070
Provider Name (Legal Business Name): TRACY COFFEY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17940 FARMINGTON RD STE 225
LIVONIA MI
48152-3195
US

IV. Provider business mailing address

2821 PRAIRIE RIDGE DR
GRASS LAKE MI
49240-9452
US

V. Phone/Fax

Practice location:
  • Phone: 248-599-2410
  • Fax:
Mailing address:
  • Phone:
  • 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: