Provider Demographics
NPI:1124228275
Name:PRUDENT-LIFESTYLES NUTRITION SERVICES, INC.
Entity Type:Organization
Organization Name:PRUDENT-LIFESTYLES NUTRITION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:TONJA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:STALLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:248-866-4967
Mailing Address - Street 1:17570 SAN ROSA BLVD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2715
Mailing Address - Country:US
Mailing Address - Phone:248-866-4967
Mailing Address - Fax:248-559-5081
Practice Address - Street 1:17570 SAN ROSA BLVD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2715
Practice Address - Country:US
Practice Address - Phone:248-866-4967
Practice Address - Fax:248-559-5081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty