Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2301007843 | MI |
NPI | 1154392843 |
---|---|
Provider Name | Dr. Craig A. Stull |
First Address | Portage, MI 49024-1118 |
Second Address | Portage, MI 49024-1118 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U75808 | (02) | MI |