Healthcare Provider Details

I. General information

NPI: 1477582898
Provider Name (Legal Business Name): JANE ANN ROTH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANE ANN MROZINSKI

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 MCLEOD DR E BAY AREA REGIONAL DIALYSIS CTR - CKD SERVICES
SAGINAW MI
48604-2839
US

IV. Provider business mailing address

545 E DAWN DR
FREELAND MI
48623-9059
US

V. Phone/Fax

Practice location:
  • Phone: 989-790-9440
  • Fax: 989-790-1335
Mailing address:
  • Phone: 989-695-5690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number14777
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: