MEDICARE: LIBERTY QUACKENBUSH RDN

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	:	1578310900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIBERTY QUACKENBUSH RDN

Provider Business Mailing Address
First Line	:	PO BOX 1327
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48804-1327
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 1327
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48804-1327
Country	:	US
Telephone Number	:	989-303-9146
Fax Number	:

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

Provider Enumeration Date	:	05/03/2024
Last Update Date	:	05/03/2024

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