Provider Demographics
NPI:1114465044
Name:PROFESSIONAL DIETITIAN SERVICES, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL DIETITIAN SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALAME
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN
Authorized Official - Phone:313-912-4798
Mailing Address - Street 1:29519 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1275
Mailing Address - Country:US
Mailing Address - Phone:586-234-3871
Mailing Address - Fax:586-343-8773
Practice Address - Street 1:29519 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1275
Practice Address - Country:US
Practice Address - Phone:586-234-3871
Practice Address - Fax:586-343-8773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-12
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIF0803N261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service