Provider Demographics
NPI:1649696568
Name:LYNN SPALDING GERONTOLOGICAL NUTRITION SPECIALIST
Entity type:Organization
Organization Name:LYNN SPALDING GERONTOLOGICAL NUTRITION SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPALDING
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CSG
Authorized Official - Phone:517-290-4816
Mailing Address - Street 1:PO BOX 871206
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-6206
Mailing Address - Country:US
Mailing Address - Phone:517-290-4816
Mailing Address - Fax:734-207-5326
Practice Address - Street 1:12516 HIDDENVALE CT
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:MI
Practice Address - Zip Code:48872-9153
Practice Address - Country:US
Practice Address - Phone:517-290-4816
Practice Address - Fax:734-207-5326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI538653133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty