Provider Demographics
NPI:1801060991
Name:GRUNER, TINA D (CDE)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:D
Last Name:GRUNER
Suffix:
Gender:F
Credentials:CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 NE A ST
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-1844
Mailing Address - Country:US
Mailing Address - Phone:541-475-3882
Mailing Address - Fax:541-475-0610
Practice Address - Street 1:480 NE A ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1844
Practice Address - Country:US
Practice Address - Phone:541-475-3882
Practice Address - Fax:541-475-0610
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC00618978133NN1002X, 133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151024Medicaid
OR00618978OtherADA MEMBERSHIP
OR381324Medicare Oscar/Certification
ORR0000ZGBFNMedicare Oscar/Certification
ORR115999Medicare Oscar/Certification