Basic Information
| Provider Information | |||||||||
| NPI: | 1659567592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEROCHA | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | R.D., C.D.E | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ARRIOLA | ||||||||
| OtherFirstName: | GRACE | ||||||||
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| OtherCredential: | R.D., C.D.E. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1333 BREWERY PARK BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134464444 | ||||||||
| FaxNumber: | 3134464445 | ||||||||
| Practice Location | |||||||||
| Address1: | 30158 TRAILWOOD DR | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480926304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135701166 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2007 | ||||||||
| LastUpdateDate: | 10/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 886178 | MI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | 174H00000X | 20920243 | MI | N | Other Service Providers | Health Educator |
No ID Information.