Healthcare Provider Details

I. General information

NPI: 1245796630
Provider Name (Legal Business Name): BETH SMITH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 POINT O WOODS DR
PORTAGE MI
49002-7191
US

IV. Provider business mailing address

35 MILLER AVE STE 273
MILL VALLEY CA
94941-1903
US

V. Phone/Fax

Practice location:
  • Phone: 269-903-5138
  • Fax:
Mailing address:
  • Phone: 415-302-3651
  • 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: