MEDICARE: KJ NUTRITION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1043015449
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KJ NUTRITION

Provider Business Mailing Address
First Line	:	14629 W OBERLIN WAY
Second Line	:
City	:	SURPRISE
State	:	AZ
Zip	:	85387-6747
Country	:	US
Telephone Number	:	719-290-0002
Fax Number	:

Provider Business Practice Location Address
First Line	:	14629 W OBERLIN WAY
Second Line	:
City	:	SURPRISE
State	:	AZ
Zip	:	85387-6747
Country	:	US
Telephone Number	:	719-290-0002
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DIETITIAN
Name	:	KELLI JO GROVER
Credential	:	MDA, RDN
Telephone Number	:	719-290-0002

Provider Enumeration Date	:	02/18/2025
Last Update Date	:	02/18/2025

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