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General NPI Number Information
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NPI Number | 1740997212
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Entity Type | Organization
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Legal Business Name | MICHIGAN NUTRIGENETICS
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Dates
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Enumeration Date | 11/03/2022
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Last Update Date | 02/08/2023
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Provider Practice Location Address
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Address Line | 6701 BOCA VISTA DR NE UNIT 102
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City | ROCKFORD
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State | MI
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Zip | 49341-9655
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Country | US
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Telephone | 616-255-5338
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Fax |
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Provider Business Mailing Address
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Address Line | 6701 BOCA VISTA DR NE UNIT 102
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City | ROCKFORD
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State | MI
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Zip | 49341-9655
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Country | US
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Telephone | 616-255-5338
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DEAN ALAN RUBLE
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Credential | DO
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Telephone | 616-255-5338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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