Basic Information
| Provider Information | |||||||||
| NPI: | 1841545811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KISCHUK | ||||||||
| FirstName: | AMANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3044 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481243504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135704271 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6245 INKSTER RD | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481354001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344583300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 07/17/2012 | ||||||||
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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 | 1040941 | MI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1040941 | 01 | MI | CDR NUMBER | OTHER |