Healthcare Provider Details

I. General information

NPI: 1811685498
Provider Name (Legal Business Name): MEDICAL NUTRITION THERAPY OF ARIZONA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6095 E GRANT RD
TUCSON AZ
85712-2343
US

IV. Provider business mailing address

6095 E GRANT RD
TUCSON AZ
85712-2343
US

V. Phone/Fax

Practice location:
  • Phone: 415-845-8654
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY TOROK
Title or Position: MANAGING OWNER
Credential: RDN
Phone: 415-845-8654