Provider Demographics
NPI:1619604410
Name:MICHIANA NUTRITION AND DIABETES EDUCATION LLC
Entity Type:Organization
Organization Name:MICHIANA NUTRITION AND DIABETES EDUCATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ANOUK
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, RD, LD, CNSC
Authorized Official - Phone:815-342-6205
Mailing Address - Street 1:16151 PETRO DR
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-6422
Mailing Address - Country:US
Mailing Address - Phone:815-342-6205
Mailing Address - Fax:
Practice Address - Street 1:300 S SAINT LOUIS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3043
Practice Address - Country:US
Practice Address - Phone:574-301-5205
Practice Address - Fax:574-301-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-02
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service