MEDICARE: MMC NUTRITION CENTER FPP

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	133N00000X	Nutritionist		NY

General Provider Information

NPI Number	:	1780910976
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MMC NUTRITION CENTER FPP

Provider Business Mailing Address
First Line	:	GPO BOX 27369
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10087-7369
Country	:	US
Telephone Number	:	718-283-8777
Fax Number	:	718-283-8796

Provider Business Practice Location Address
First Line	:	4702 FORT HAMILTON PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-2926
Country	:	US
Telephone Number	:	718-283-8777
Fax Number	:	718-283-8796

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MARTIN CAMMER
Credential	:
Telephone Number	:	718-283-8773

Provider Enumeration Date	:	10/23/2009
Last Update Date	:	10/23/2009

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