Provider Demographics
NPI:1114585015
Name:GEORGIADIS, ALEXANDRA (RD)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:GEORGIADIS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 W GRAND RIVER AVE STE A
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1604
Mailing Address - Country:US
Mailing Address - Phone:248-479-4497
Mailing Address - Fax:
Practice Address - Street 1:4410 ARAPAHOE AVE STE 110
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1135
Practice Address - Country:US
Practice Address - Phone:720-315-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86021201133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered