MEDICARE: PERSONAL NUTRITION, INC

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	:	1740495431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERSONAL NUTRITION, INC

Provider Business Mailing Address
First Line	:	PO BOX 203098
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78720-3098
Country	:	US
Telephone Number	:	512-745-0868
Fax Number	:

Provider Business Practice Location Address
First Line	:	11673 JOLLYVILLE RD STE 202
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-4211
Country	:	US
Telephone Number	:	512-745-0868
Fax Number	:	866-372-0980

Authorized Official
Title or Position	:	REGISTERED DIETITIAN, PRESIDENT
Name	:	STACY FISHER
Credential	:	RD, LD
Telephone Number	:	512-745-0868

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	04/08/2008

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