Provider Demographics
NPI:1396160388
Name:GRAND TRAVERSE NUTRITION, LLC
Entity type:Organization
Organization Name:GRAND TRAVERSE NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONROE
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:231-632-1522
Mailing Address - Street 1:PO BOX 6263
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-6263
Mailing Address - Country:US
Mailing Address - Phone:231-632-1522
Mailing Address - Fax:
Practice Address - Street 1:800 COTTAGEVIEW DR
Practice Address - Street 2:SUITE 1076
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2616
Practice Address - Country:US
Practice Address - Phone:231-632-1522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI851200OtherRDN - COMMISSION DIETETIC REGISTRATION