Provider Demographics
NPI:1922702638
Name:TABATA, BRENT TANNIN (MS, RD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:TANNIN
Last Name:TABATA
Suffix:
Gender:M
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 LAFAYETTE AVE SE STE 400
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4677
Practice Address - Country:US
Practice Address - Phone:616-486-6870
Practice Address - Fax:616-454-6898
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI973751133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered