Provider Demographics
NPI:1659199032
Name:DATSENKO, GEORGE (RDN)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:DATSENKO
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-1974
Mailing Address - Country:US
Mailing Address - Phone:248-688-7858
Mailing Address - Fax:
Practice Address - Street 1:353 MADISON AVE
Practice Address - Street 2:
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017-1974
Practice Address - Country:US
Practice Address - Phone:248-688-7858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1050445133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered