Provider Demographics
NPI:1831458801
Name:BALMER, PHYLLIS (RD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:BALMER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 RIPLEY RD
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-9467
Mailing Address - Country:US
Mailing Address - Phone:810-955-6582
Mailing Address - Fax:810-735-5309
Practice Address - Street 1:1217 RIPLEY RD
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-9467
Practice Address - Country:US
Practice Address - Phone:810-955-6582
Practice Address - Fax:810-735-5309
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI00107887133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered