MEDICARE: ECNUTRITION LLC

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	133VN1201X	Obesity and Weight Management Nutrition Registered Dietitian
2	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1568051100
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ECNUTRITION LLC

Provider Business Mailing Address
First Line	:	240 MILLRACE RD
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-3837
Country	:	US
Telephone Number	:	248-563-6866
Fax Number	:

Provider Business Practice Location Address
First Line	:	4050 W MAPLE RD STE 108
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301-3118
Country	:	US
Telephone Number	:	248-563-6866
Fax Number	:

Authorized Official
Title or Position	:	SOLE MBR
Name	:	EMILY H CAMIENER
Credential	:	RDN
Telephone Number	:	248-563-6866

Provider Enumeration Date	:	01/17/2021
Last Update Date	:	08/17/2021

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