Healthcare Provider Details

I. General information

NPI: 1003047440
Provider Name (Legal Business Name): TONI FAYE HAITHCOCK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2009
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 E 13 MILE RD APT 205
MADISON HEIGHTS MI
48071-5020
US

IV. Provider business mailing address

PO BOX 71732
MADISON HEIGHTS MI
48071-0732
US

V. Phone/Fax

Practice location:
  • Phone: 586-604-6585
  • Fax:
Mailing address:
  • Phone: 586-604-6585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number812626
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number812626
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number812626
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: