Healthcare Provider Details

I. General information

NPI: 1265889612
Provider Name (Legal Business Name): THRIVE PEDIATRIC NUTRITION SPECIALISTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 OFFICE PARK DR STE 205
MOUNTAIN BRK AL
35223-2455
US

IV. Provider business mailing address

2925 VIRGINIA RD
MOUNTAIN BRK AL
35223-1253
US

V. Phone/Fax

Practice location:
  • Phone: 205-704-1641
  • Fax:
Mailing address:
  • Phone: 205-704-1641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number1814
License Number StateAL

VIII. Authorized Official

Name: MRS. ALI HOWARD ELLIOTT
Title or Position: REGISTERED DIETITIAN
Credential: MS, RDN, LD, CLC
Phone: 205-704-1641