Healthcare Provider Details

I. General information

NPI: 1609219872
Provider Name (Legal Business Name): MEDICAL NUTRITION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 06/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1198 W KELLY LN
TEMPE AZ
85284-3772
US

IV. Provider business mailing address

1198 W KELLY LN
TEMPE AZ
85284-3772
US

V. Phone/Fax

Practice location:
  • Phone: 480-204-6006
  • Fax: 480-436-6006
Mailing address:
  • Phone: 480-204-6006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: KRISTA M SIMONETTI
Title or Position: OWNER
Credential: MS, CNS
Phone: 480-204-6006