Healthcare Provider Details

I. General information

NPI: 1114465044
Provider Name (Legal Business Name): PROFESSIONAL DIETITIAN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2017
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29519 HARPER AVE
SAINT CLAIR SHORES MI
48081-1275
US

IV. Provider business mailing address

29519 HARPER AVE
SAINT CLAIR SHORES MI
48081-1275
US

V. Phone/Fax

Practice location:
  • Phone: 586-234-3871
  • Fax: 586-343-8773
Mailing address:
  • Phone: 586-234-3871
  • Fax: 586-343-8773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberF0803N
License Number StateMI

VIII. Authorized Official

Name: MRS. AMANDA ALAME
Title or Position: REGISTERED DIETITIAN
Credential: MS, RDN
Phone: 313-912-4798