MEDICARE: NORTH TEXAS NUTRITION CONSULTANTS

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	DT82634	TX

General Provider Information

NPI Number	:	1720432594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH TEXAS NUTRITION CONSULTANTS

Provider Business Mailing Address
First Line	:	805 TERRY TRL
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4601
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 AUSTIN AVE STE 107
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-3381
Country	:	US
Telephone Number	:	817-629-0420
Fax Number	:	817-776-8150

Authorized Official
Title or Position	:	PRESIDENT/REGISTERED DIETITIAN
Name	:	JONATHAN SHANE CLACK
Credential	:	RD
Telephone Number	:	817-629-0420

Provider Enumeration Date	:	04/19/2016
Last Update Date	:	05/26/2016

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