1427612639 NPI number — GO EAT WISE

Table of content: (NPI 1427612639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427612639 NPI number — GO EAT WISE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GO EAT WISE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427612639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17340 W 12 MILE RD STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48076-6322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-234-4212
Provider Business Mailing Address Fax Number:
248-856-4697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17340 W 12 MILE RD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48076-6322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-234-4212
Provider Business Practice Location Address Fax Number:
248-856-4697
Provider Enumeration Date:
04/24/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ELKINS
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
D
Authorized Official Title or Position:
REGISTERED DIETITIAN
Authorized Official Telephone Number:
248-519-3960

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)