MEDICARE: SUSTAINABLE NOURISHMENT NUTRITION THERAPY, LLC

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	:	1295358174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSTAINABLE NOURISHMENT NUTRITION THERAPY, LLC

Provider Business Mailing Address
First Line	:	11807 WESTHEIMER ROAD
Second Line	:	SUITE 550 PMB 641
City	:	HOUSTON
State	:	TX
Zip	:	77077
Country	:	US
Telephone Number	:	214-491-9346
Fax Number	:

Provider Business Practice Location Address
First Line	:	3805 W ALABAMA ST APT 4107
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77027-5248
Country	:	US
Telephone Number	:	214-491-9346
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED DIETITIAN
Name	:	CASSIDY CAMISCIONE
Credential	:	RD
Telephone Number	:	214-491-9346

Provider Enumeration Date	:	05/26/2020
Last Update Date	:	05/26/2020

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