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General NPI Number Information
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NPI Number | 1396160388
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Entity Type | Organization
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Legal Business Name | GRAND TRAVERSE NUTRITION, LLC
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Dates
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Enumeration Date | 02/27/2014
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Last Update Date | 02/27/2014
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Provider Practice Location Address
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Address Line | 800 COTTAGEVIEW DR SUITE 1076
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City | TRAVERSE CITY
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State | MI
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Zip | 49684-2616
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Country | US
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Telephone | 231-632-1522
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6263
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City | TRAVERSE CITY
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State | MI
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Zip | 49696-6263
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Country | US
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Telephone | 231-632-1522
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Fax |
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Authorized Official
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Title or Position | MEMBER/OWNER
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Name | MS. MIRANDA MONROE
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Credential | RDN
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Telephone | 231-632-1522
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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