MEDICARE: MS. MANDY MICHELE GRUNER MS, RD, CSSD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1538386396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MANDY MICHELE GRUNER MS, RD, CSSD

Provider Business Mailing Address
First Line	:	826 PARCHMENT DR SE STE 100
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2307
Country	:	US
Telephone Number	:	616-957-7700
Fax Number	:	616-957-7773

Provider Business Practice Location Address
First Line	:	826 PARCHMENT DR SE STE 100
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2307
Country	:	US
Telephone Number	:	616-957-7700
Fax Number	:	616-957-7773

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	12/19/2008

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