Provider Demographics
NPI:1053853168
Name:GARDENS AT ROUNDTABLE
Entity Type:Organization
Organization Name:GARDENS AT ROUNDTABLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:TILT
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CSP
Authorized Official - Phone:765-630-7222
Mailing Address - Street 1:904 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47901-1416
Mailing Address - Country:US
Mailing Address - Phone:765-630-7222
Mailing Address - Fax:765-807-3210
Practice Address - Street 1:904 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47901-1416
Practice Address - Country:US
Practice Address - Phone:765-630-7222
Practice Address - Fax:765-807-3210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty