Healthcare Provider Details

I. General information

NPI: 1174703144
Provider Name (Legal Business Name): MICHELLE RENAEE HALECK MS, RD,LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 03/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RISNER DR ELLSWORTH AIR FORCE BASE
ELLSWORTH AFB SD
57706-4704
US

IV. Provider business mailing address

2450 RISNER DR ELLSWORTH AIR FORCE BASE
ELLSWORTH AFB SD
57706-4704
US

V. Phone/Fax

Practice location:
  • Phone: 605-385-2349
  • Fax:
Mailing address:
  • Phone: 605-385-2349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT80312
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: