Healthcare Provider Details

I. General information

NPI: 1649696568
Provider Name (Legal Business Name): LYNN SPALDING GERONTOLOGICAL NUTRITION SPECIALIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2014
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12516 HIDDENVALE CT
PERRY MI
48872-9153
US

IV. Provider business mailing address

PO BOX 871206
CANTON MI
48187-6206
US

V. Phone/Fax

Practice location:
  • Phone: 517-290-4816
  • Fax: 734-207-5326
Mailing address:
  • Phone: 517-290-4816
  • Fax: 734-207-5326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number538653
License Number StateMI

VIII. Authorized Official

Name: LYNN SPALDING
Title or Position: OWNER
Credential: RD, CSG
Phone: 517-290-4816