Basic Information
| Provider Information | |||||||||
| NPI: | 1710109335 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHILDERS | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5491 SOUTH ROSEBUD COURT SE #1 | ||||||||
| Address2: | |||||||||
| City: | KENTWOOD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167800430 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 555 LINN STREET | ||||||||
| Address2: | |||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696864251 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 911821 | TN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.