Basic Information
| Provider Information | |||||||||
| NPI: | 1215688122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUFFONE | ||||||||
| FirstName: | JAKE | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 642 GRUBER ST APT B5 | ||||||||
| Address2: | |||||||||
| City: | FRANKENMUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487341033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484212666 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4800 S SAGINAW ST | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485072677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107328336 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2022 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | MI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.