Provider Demographics
NPI:1710109335
Name:CHILDERS, CHRISTOPHER MICHAEL (RD)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:MICHAEL
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5491 SOUTH ROSEBUD COURT SE #1
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512
Mailing Address - Country:US
Mailing Address - Phone:616-780-0430
Mailing Address - Fax:
Practice Address - Street 1:555 LINN STREET
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010
Practice Address - Country:US
Practice Address - Phone:269-686-4251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN911821133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered